Okaloosa County BOCC — April 4, 2017 — Amendment to GSB — reading text

ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANGE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION I8 WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUGER CONIACT Revin Kruizenga Brown & Brown of Kentucky, Inc ‘A,C N e (270)384-5800 mé Noj; (270) 384-5400 ADNllll'l\!ESS: kkruizenga@reedbrothersinsurance.com PO Box 9 INSURER(S) AFFORDING COVERAGE NAIC # Columbia KY 42728 INSURER A Hallmark Insurance Company 34037 INSURED INSURER B : GSB Holdings, LLC INSURERC : 10241 Destination Dr. INSURERD : INSURERE : Hammond LA 70403 INSURER F 1 COVERAGES CERTIFICATE NUMBER:CL173305737 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUGH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL[SUBR| POLICY EFF | POLICY EXP LTR TYPE OF INSURANCE INSD | WWVD. POLICY NUMBER (MNUDD/YYYY) | (MW/DDIYYYY) LIMITS X | COMMERCIAL GENERAL LIABILITY EACH OGCURRENGE $ DAMAGE TO RENTED A J CLAIMS-MADE @ OCGUR PREMISES (Ea occurrence) | $ AP99-07934~01 12/22/2016|12/22/2017 | MED EXP (Any one person) | § PERSONAL & ADVINJURY | § GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 1,000,000 X | poLicy l:l S D Loc PRODUCTS - COMPIOP AGG | § OTHER: $ AUTOMOBILE LIABILITY %%“g‘gy&%fi )SlNG'-E LT g ANY AUTO BODILY INJURY (Per parson) | $ ALL OWNED SCHEDULED : HIRED AUTOS AUTOS (Per accident) A $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED | ‘ RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS' LIABILITY YIN Sthrure | [ 2% ANY PROPRIETOR/PARTNER/EXECUTIVE E L. EACH ACGIDENT $ OFFICER/MEMBER EXCLUDED? I:] N/A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ If yas, describe unde: DESCRIBTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | § DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Destin-Fort Walton Beach Airport CERTIFICATE HOLDER ) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Additional Insured: ACCORDANGE WITH THE POLICY PROVISIONS. Okaloosa County 5749 A Old Bethel Road Crestview, FL 32536 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 2014011 Additional Named Insureds Other Named Insureds Dixie RV SuperStores of NW Florida Doing Business As OFAPPINF (02/2007) COPYRIGHT 2007, AMS SERVICES INC POLICY NO.: NAI6003798 ATTACHED TO CERTIFICATE # 5 CERTIFICATE OF INSURANCE THIS IS TO CERTIFY TO: Okaloosa County 5749 A Old Bethel Road Crestview, FL 32536 THAT THE FOLLOWING POLICY OF INSURANCE HAS BEEN ISSUED TO: Dixie Motors, LLC and Dixie Air of Hammond, LLC 10241 Destination Drive Hammond, LA 70403 POLICY NUMBER: NAIB003798 POLICY PERIOD: From September 19, 2016 To September 19, 2017 INSURANCE COMPANY: Endurance American Insurance Co. DESCRIPTION OF COVERAGES AND LIMITS OF LIABILITY: Please refer to attached schedule which is incorporated as a part hereof. The above Certificate Holder is included as an Additional Insured but only to the extent of liability imposed upon the Additional Insured solely as the result of an act or omission of the Named Insured or its employees in connection with the Named Insured's Operations. Subject to Date Change Recognition Endorsement. Data included in this Certificate valid as of March 7, 2017. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policies. Should the described policy be cancelled before the expiration date hereof, the issuing company wil! endeavor to give 30 days (10 days for non-payment) notice to the certificate holder named herein. However, failure to mail such notice shall not impose any obligation nor any liability of any kind upon the Company, its representatives or agents. By: W’”fl") Date of Issue: March 7, 2017 W. Brown & Associates Insurance Services Certificate No.: 5§ Certificate # 5 Page 1 0of 2 POLICY NO.: NAIG003798 ATTACHED TO CERTIFICATE # & SCHEDULE OF AIRCRAFT DESCRIPTION OF AIRCRAFT No. |FAA Cert# |Serial # Year/Make/Model Insured Value 1 |N281RV 0465 2013 Cirrus SR22 $750,000 2 |N851RV 50000260 2011 Embraer Phenom 100 $3,500,000 PHYSICAL DAMAGE COVERAGE Deductibles No. Not In Motion In Motion Physical Damage Coverage 1 Nil Nil F. All Risk Basis Nil Nil F. All Risk Basis AIRCRAFT LIABILITY COVERAGES Single Limit Bodily Injury Passenger Passenger Liability Limited To No. & Property Damage Liability Each Person Each Occurrence 1 $1,000,000{ Included XXX XXXX 2 $10,000,000| included XXX XXXX MEDICAL EXPENSES No. Including Crew Each Person Each Occurrence 1 Yes $25,000 $125,000 2 Yes $25,000 $200,000 Certificate # 5_ Page 2 of 2