ACORD - lake.k12.fl.us · CERTIFICATE HOLDER CANCELLATION ... Zurich - Account Service Center ......
Transcript of ACORD - lake.k12.fl.us · CERTIFICATE HOLDER CANCELLATION ... Zurich - Account Service Center ......
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCETHIS 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).
CONTACTPRODUCER NAME:FAXPHONE(A/C, No):(A/C, No, Ext):
E-MAILADDRESS:
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A :INSURED INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: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.
ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY) (MM/DD/YYYY)INSD WVD
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $DAMAGE TO RENTED
CLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT
$OTHER:COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident)BODILY INJURY (Per person) $ANY AUTO
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $AUTOS AUTOSNON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS
$
UMBRELLA LIAB EACH OCCURRENCE $OCCUREXCESS LIAB CLAIMS-MADE AGGREGATE $
$DED RETENTION $PER OTH-WORKERS COMPENSATIONSTATUTE ERAND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $If yes, describe under
E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED INACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
© 1988-2014 ACORD CORPORATION. All rights reserved.The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01)
COCOFOR-01 FOUNTIAND
10/15/2014
Insurance Office of America-JAX1 Sleiman Parkway, Suite 130Jacksonville, FL 32216
(904) 448-9777 (904) 448-9788
FHM Insurance Company 10699
Cocoa Ford Inc dba Paradise Ford1360 W. King St.Cocoa, FL 32922
XA WC306-0021103-2014 05/01/2014 05/01/2015 500,000Y
500,000500,000
School Board of Lake County, FloridaAttn: Purchasing201 West Burleigh BlvdTavares, FL 32778
DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE 10/16/2014
PRODUCER
INSURER(S) AFFORDING COVERAGE NAIC #INSURED INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
Zurich - Account Service Center7045 College BlvdOverland Park, KS 66211Fax: 888-734-6776 Ph: 877-225-5276
COCOA FORD, INC. DBA; PARADISE FORD1360 WEST KING STREETCOCOA, FL 32922
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 CERTICATE HOLDERIMPORTANT: 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).
CONTACTNAME:
PHONE(A/C No. EXT):E-MAILADDRESS:
FAX(A/C No):
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 THIS
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
Zurich - Account Service Center
877-225-5276 888-734-6776
Universal Underwriters Insurance Company 41181002233600
INSRLTR
TYPE OF INSURANCE ADD’LINSRD
SUBRWVD
POLICY EFF POLICY EXP(MM/DD/YYYY) LIMITSPOLICY NUMBER (MM/DD/YYYY)
POLICY PROJECT LOC
DAMAGE TO RENTEDPREMISES (Ea occurrence)
EACH OCCURENCE
MED EXP (Any one person)
PERSONAL & ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP/OP AGG
GENERAL LIABILITY
COMMERICAL GENERAL LIABILITY
CLAIMS MADE OCCUR
GEN’L AGGREGATE LIMIT APPLIES PER:
05/01/2014 05/01/2015281531
AX
X
$500,000
$
$
$
$
$
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
COMBINED SINGLE LIMIT
COMP/COLL DED
(Ea Accident)
NON-OWNED AUTOS
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE(Per accident)
$
$
281531 05/01/2014 05/01/2015
AX
XX
$500,000
$
$
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS-MADE
DEDUCTIBLE
EACH OCCURRENCE
RETENTION
AGGREGATE
PRODUCTS - COMP/OP AGG
$
281531 05/01/2014 05/01/2015
A X X
X
$5,000,000
$
$
$0
WORKERS COMPENSATION ANDEMPLOYERS’ LIABILITYANY PROPRIETOR/PARTNER/EXECUTIVE
WC STATU-
OFFICER/MEMBER EXCLUDED? E.L. EACH ACCIDENT
E.L. DISEASE -EA EMPLOYEE
E.L. DISEASE - POLICY LIMIT
TORY LIMITS
(Mandatory in NH)If yes, describe underDESCRIPTION OF OPERATIONS below
OTH-ER
Y/NN/A
$
$
$GARAGE LIABILITY
ANY AUTO
OTHER THAN AUTO ONLYEACH ACC:281531 05/01/2014 05/01/2015A
X$500,000
281531 05/01/2014 05/01/2015A $8,140,850Customer Auto - Direct Primary
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Reason for Certificate:General Liability
30 Day notice of cancellation applies, except for cancellation due to non payment of premium.See Additional Remarks Schedule Attached
CANCELLATIONCERTIFICATE HOLDER
AUTHORIZED REPRESENTATIVEAttn:Fax:
SCHOOL BOARD OF LAKE COUNTY, FLORIDA201 WEST BURLEIGH BOULEVARDTAVARES, FL 32778
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
PURCHASING
© 1988–2010 ACORD CORPORATION, All rights reservedThe ACORD name and logo are registered marks of ACORDACORD 25 (2010/05)
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
© 1988–2010 ACORD CORPORATION, All rights reservedThe ACORD name and logo are registered marks of ACORDACORD 25 (2010/05)
AGENCY CUSTOMER ID:LOC #:
ADDITIONAL REMARKS SCHEDULEAGENCY NAMED INSURED
POLICY NUMBER
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,FORM NUMBER: FORM TITLE:
Page of
COCOA FORD, INC. DBA; PARADISE FORD1360 WEST KING STREETCOCOA, FL 32922
Zurich - Account Service Center
281531
Universal Underwriters Insurance Company 41181 05/01/2014
1 1
002233600
25 Certificate of Liability Insurance
Endorsement 089-Umbrella Limit Inclusive applies.
The School Board of Lake County and its Members, Officers, and Employees are named as Additional Insured
© 2008 ACORD CORPORATION, All rights reserved.The ACORD name and logo are registered marks of ACORD
ACORD 101 (2008/01)
ACO~' DATE (MMIODIVYYY)CERTIFICATE OF LIABILITY INSURANCE 283 ~ 04i2f12015I 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 POLIC~ES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED REPR~SENTATIVE OR PRODUCER, AND THE CERTICATE HOLDER
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED. the policy(ies) must be endorsed. If SUBROGATION IS WAIVED. s~bject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to t~e certificate holder in lieu of such endorsement(s). I
PRODUCER "
CONTACT Zurich - Account Service CenterZurich - Account Service Center NAME: I 7045 College Blvd PHONE IIFAX(Alc No. EXT): 877-225-5276 (AIC No): 888-734-6776Overland Park, KS 66211 Fax: 888-734-6776 Ph: 877-225-5276 E-MAIL. .
ADDRESS: [email protected] i INSURER(S) AFFORDING COVERAGE NAle.
INSURED 002233600 INSURER A: Universal Underwriters Insurance Company 41181 COCOA FORD. INC DBA PARADISE FORD INSURERB: I 1360 WEST KING STREET
INSURERC:COCOA, FL 32922
INSURERD: i
INSURER E: i
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: i 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 THISi 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, I
INSR LTR
TYPE OF INSURANCE ADD'L SUBR 11I5RD \WD
POLICV NUMBER POLICYEFF (MMlDDlVYYY)
POLICY EXP (MMIODlVYYY) LIMITS
i
lAl GENERAL LIABILITY
IX] COMMERICAL GENERAL LIABILITY
DO CLAIMS MADE IX] OCCUR
0 0 GEN'L AGGREGATE LIMIT APPLIES PER'
0 0
281531 0510112015 05/0112016
EACH OCCURENCE
DAMAGE TO RENTED PREMISES (Ea occurrence!
MED EXP (Anyone person!
PERSONAL &ADV INJURY
GENERAL AGGREGATE
$500.000
$
$
$
$
i
•
o POLICY o PROJECT 0 LOC PRODUCTS COMPIOP AGG $
i
(AI AUTOMOBILE LIABILITY
\Xl ANY AUTO
o ALL OWNED AUTOS
0 0 COMBINED SINGLE !-IMIT (Ea Accident!
BODILY INJURY (Per personl
$500,000
$
::
o SCHEDULED AUTOS
00 HIRED AUTOS
281531 0510112015 05/0112016 BODILY INJURY (Per accident!
PROPERTY DAMAGE (Per accident)
$
$
IX] NON·OWNED AUTOS
I 0 COMPICOLL DED
$
$
(AI 00 UMBRELLA LIAB [Xl OCCUR 0 0 EACH OCCURRENCE $5,000,000 •
o EXCESS LIAB o CLAIMS·MADE AGGREGATE $
o DEDUCTIBLE 281531 05/0112015 05101/2016 PRODUCTS· COMPIOP AGG $
00 RETENTION $0 $
0 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY
01 we STATU· ;101 OTH·TORY LIMITS ER
;
ANY PROPRIETORIPARTNERlEXECUTIVE YINOFFICERIMEMBER EXCLUDED? 0(Mandatory In NH)
N/A 0 EL EACH ACCIDENT
E,!.. DISEASE ·EA EMPLOYEE
$
$
i , i
If yes, describe under DESCRIPTION OF OPERATIONS below EL DISEASE· POLICY LIMIT $ I
~ GARAGE LIABILITY
IX] ANY AUTO 0 0 281531 0510112015 05/0112016
OTHER THAN AUTO ONLY EACH ACC' $500,000
, I
lAl Customer Auto Direct Primary 0 0 281531 05/0112015 0510112016 $6.905,280 I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule. if more space is required) I I
Reason for Certificate:GENERAL LIABILITY I
30 Day notice of cancellation applies, except for cancellation due to non payment of premium. ! See Additional Remarks Schedule Attached
CERTIFICATE HOLDER CANCELLATION SCHOOL BOARD OF LAKE COUNIY, FLORIDA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED IJ!EFORE
201 WEST BURLEIGH BOULEVARD THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.TAVARES.. FL 32778
AUTHORIZED REPRESENTATIVE Attn: PURCHASING Fax:
'-f}uttt D. YYJ~ ii
© 1988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED. the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s). authorized representative or producer. and the certificate holder. nor does it affirmatively or negatively amend. extend or alter the coverage afforded by the policies listed thereon.
© 1988-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
285
AGENCYCUSTOMERID:~0~0~2~23~3~6~00~____________________ LOC#'
Pa e1 of 1ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED
Zurich· Account Service Center COCOA FORD. INC. DBA PARADISE FORD 1360 WEST KING STREET
POLICY NUMBER COCOA. FL 32922 281531
CARRIER /NAICCODE
Universal Underwriters Insurance Company 41181 EFFECTIVE DATE: 0510112015
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I 25 Certificate of Liability Insurance
. FORM NUMBER: FORM TITLE:
1
Endorsement 08g-Umbrella Limit Inclusive applies.
The School Board of Lake County and its Members. Officers. and Employees are named as Additional Insured I
ACORD 101 (2008/01) © 2008 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD