Okaloosa County BOCC — March 1, 2016 — UniversalCablingIns

- ACORD CERTIFICATE OF LIABILITY INSURANCE 12/9/2015 THIS CERTIFICATE IS 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 INSURANCE 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 IS 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). PRODUCER COMIACT Bekah Pickering Lassiter-Ware Insurance of Maitland PHONE Eqy (800)845-8437 [ FBX o). (888) 883-8680 2701 Maitland Center Parkway EMAL 5. BekahP@lassiter-ware.com Suite 125 INSURER(S) AFFORDING COVERAGE NAIC # Maitland FL 32751 nsurerAAllied Property & Casualty 42579 INSURED iNsurRerB:Zenith Insurance Co. 13269 Universal Cabling Systems, Inc. INSURER C : INSURER D : 914 Fern Street INSURERE : West Palm Beach FL 33401 INSURERF : COVERAGES CERTIFICATE NUMBER:16/17 WC 15/16 P&C 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 SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADDL|SUBR BOLICY EFF | PO ILTR TYPE OF INSURANCE INSR | WVD. POLICY NUMBER (MM/DD/YYYY) (MM%%W) LIMITS GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 - DAMAGE TO RENTED X | COMMERCIAL GENERAL LIABILITY PREMISES(()Eanccurrence) S 100,000 A | cLams mape OCCUR X [ACP5935472566 5/11/2015 |5/11/2016 | yEpEXP (Any one person) | § 10,000 . PERSONAL & ADV INJURY | § 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG | § 2,000,000 poLicy | X | 7B LOC s COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea accident) $ 1,000,000 A X | ANY AUTO BODILY INJURY (Per person) | § fibgrgg\/NED iSl_l'_iggULED IACP5935472566 I5/11/2015 |5/11/2016 | BODILY INJURY (Per accident)| $ ] NON-OWNED PROPERTY DAMAGE s HIRED AUTOS AUTOS (Per accident) s X |umBreLLaLAB | X | occur EACH OCCURRENCE s 3,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE s 3,000,000 oeo | X | retentions 0 ACP5935472566 5/11/2015 [5/11/2016 s B | WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY YIN X | ToRY LimiTs ER ANY é’RO;RIETOR/PARTNERIEXECUTIVE NiA E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Z070501507 1/1/2016 [1/1/2017 | g D|SEASE - EA EMPLOYEH § 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT | § 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Okaloosa County, and its respective agents, consultants, servants, and employees of each and all other interests are named as additional insured under the terms and conditions of the general liability policy with respects to work being performed by the named insured as required by written contract. The general liability policy contains a Waiver of Subrogation in favor of the certificate holder providing the contract is executed prior to any loss. This insurance shall be primary and non-contributory. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Okaloosa County 602-C North Pearl Street Crestview, FL 32536 AUTHORIZED REPRESENTATIVE B —— & Pau