Okaloosa County BOCC — December 16, 2014 — HEND-RX NUTRITION LEASE COORDINATION SHEET, LEASE AND INSURANCE — reading text

By: President/Owner | ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE (MIDDAY) 12/09/14 PRODUCER GULFSIDE INS - FT WALTON 109 FERRY RD SE FT WALTON, FL 32547 THIS CERTIFICATE [S ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Phone: (850) 243-0300 Fax: (850) 243-0347 INSURERS AFFORDING COVERAGE INSURED ! HENDRICKS, GARY dba HENDRICKS NUTRITION AND aaa Lioyds of Dondon LABORATORY INSURER 3 “I 205 KELLY AVE — FT WALTON BEACH, FL 32548 oes Phone: (850) 313-4731 ° ; COVERAGE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTHWITHSTANDING 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. AGGREGATE TINS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LR DATE (MM/DD/YY) DATE (MM/DDIVY) : GENERAL LIABILITY EACH OCCURANCE § 1,000,000 [| COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any one fire) $100,600 CLAIMS MADE [X] OCCUR MED EXP(Any one person) 5,000 A MERCFLOO6007 11/05/2014 11/05/2015 PERSONAL AND ADV INJURY $ Excluded GENERAL AGGREGATE § 1,000,000 : EN. AGGREGATE LIMIT APPLIES PRODUCTS - COMP/OP AGG $ Excluded | i [x] Poucy [] pRouecr[] Loc [AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ C] any AuTO (ea accident) [| ALL OWNED AUTOS BODILY INJURY 3 H SCHEDULED AUTOS (Per person) i [-] HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS. (Per accident) al PROPERTY DAMAGE 3 (Per accident) GARAGE LIABILITY [AUTO ONLY - EA ACCIDENT $ [] ANY AUTO OTHER THAN EA ACC. $ ri JAUTO ONLY: AGG [F EXCESS LIABILITY EACH OCCURANCE $ | [occur [] cLaims mabe AGGREGATE $ H DEDUCTIBLE 3 RETENTION 3 WORKERS COMPENSATION AND [_[wc STATUTORY EMPLOYERS LIABILITY Civirs [] oTHER E.L. EACH ACCIDENT $ .L.DISEASE-EA EMPLOYEE $ fE.L.DISEASE - POLICY LIMIT 8 : OTHER H H DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDROUSMENT/SPECIAL PROVISIONS {NUTRITION SPEACILIST CERTIFICATE HOLDER I x [ADDITIONAL INSURED:INSURED LETTER: [A [CANCELLATION jOKALOOSA COUNTY DEPT OF GROWTH MGMT 41804 LEWES TURNER BLVD FT WALTON BEACH, FL 32547 Faxed to: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL_10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TG NO ISO SHALL IMPOSE NO OBLIGATION ON LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE i fe HE ACCORD 26-8 (7/97) ACORD CORPORATION 1988