Certificates of Insurance
.. . .(';.!.~.I~I~~!~ o!...l!'surance
.;rh1S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER THIS
CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED
BELOW.
This is to Certify that
Staff Leasing, L.P., Total Employee Leasing Services,
L.P., Horida Payroll Leasing & Services, L.P. , Staff Leasing, GA,
L.P., and It's Affiliates and Subsidiaries
1301 6th Ave. West Suite ]01
Bradenton FL 34206
Name and
address of
Insured
LIBERlY.
MUTUALW
is, at the issue date of this certificate, insured by the Company under the poiicy(ies) listed below. The insurance afforded by the
listed policy(ies) is subject to all their terms, exciusions and conditions and is not altered by any requirement, term or condition of
anv contract or other document with reSDect to which this certificate mav be issued.
r;ERTIFlCATE EXP. DATE
TYPE OF POLICY " 0 CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
o EXTENDED
1KI POLICY TERM
Coverage Afforded Under WC EMPLOYERS LIABILITY
Law of the Following States:
FL,GA,AL,AZ,IN,IL Bodily Injury By Accident Each
WORKERS KY,MS,NC,SC,TN, 1 ,000,000. Ao'~."t
COMPENSATION 3-1-95 WC1-651-004110-014 MI,MO,TX,LA,NH, Bodily Injury By Disease Policy
PA,MD,NY,VA ,CT 1,000,000. Limit
Bodily Injury By Disease Each
1,000,000. Person
GENERAL LIABILITY General Aggregate-Other than Prod/Completed Operations
o CLAIMS MADE Products/Completed Operations Aggregate
I RETRO DATE I Bodily Injury and Property Damage Liability Per
APPROV Occurrence
5 BY R'AAN~GEMENT Personal and Advertising Injury Per Person!
o OCCURRENCE BY -....d r AL// Organization
, o /,? -'1 -?<-/ Other: I Other:
nne
AUTOMOBILE c.-/m Each Accident - Single Limit-
LIABILITY WAIVER: NIA B. I. and P. D. Combined
DOWNED Each Person
0 NON.OWNED Each Accident or Occurrence
r.t~cei ved
0 HIRED Risk ~': '.Tnt & I Am[~, Control Each Accident or Occurrence
1 ,~'T"-': /.;2 - " -1 y-
OTHER .,,__:::t::??____._ ___...
[;-..l1~\;.,':,.L -.
ADDITIONAL COMMENTS Employees leased to : Their Effective Date:
2832 : 07/03/94
AMERICAN ENERGY & SHEET METAL CORP
The above referenced Worker's Compensation policy provides statutory benefits only to employees of the Named Insured(s} on the policy, not
to employees of any other employer.
"IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM. YOU WILL BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED
BEFORE THE CERTIFICATE EXPIRATION DATE. HOWEVER, YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE.
SPECIAL NOTICE. OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS Liberty Mutual
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT Insurance Group
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES
UNTIL AT LEAST ;N DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO,
MONROE COUNTY BOARD OF COUNTY
5100 COLLEGE RD
KEY WEST, FL 33040
11/07/94
Orlando
OFFICE
CERTIFICATE
HOLDER
DATE ISSUED
This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by Those Companies
as 772R6
r--.
I A4I~OIII..
.
PRG-Oi1tE~
CERTIFlCATE..OF'INSURANCE
Gulf Insurance Assoc.
Mutual Benefit Assoc.
503 Marahall Street
Clearwater, Fl. 34615
....
DATE (MMfDDIYY)
11-9-94
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
-~-~,.-.---
COMPANIES AFFORDING COVERAGE
COMPANY
A
NOVA Casualty Company
INSURED
American Energy & Sheet Metal Corp.
116 N.E. Homestead Blvd.
Homestead, Fl. 33030
COMPANY
B
COMPANY
C
I
~__J
I
COMPANY
D
COVERAGES
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,
I CO II POLICY EFFECTIVE I I POliCY EXPlRAnON i
TYPE OF INSURANCE POLICY NUMBER
LTR: DATE (MMlDDfYY) i DATE (MMlDDfYY) J
I Gf::NERAl LIABILITY , GENERAL AGGREGATE
A, 'I ~ COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPIOP AGG
lu I I CLAIMS MADE :XX; OCCUR 09 AL 00 7110 4-6-94 4-6-95 PERSONAL&ADVINJURY
,
I : OWNER'S & CONT PROT
I
LIMITS
EACH OCCURRENCE
$1,000,000
$ 1,000,000
$ 1,000,000
$ 1,000,000
$ 50,000
1$ 5,000
.
I AlJTOUOBllE LIABILITY
I 1 ANY AUTO
: ALL OWNED AUTOS
: SCHEDULED AUTOS
I HIRED AUTOS
.. NON-OWNED AUTOS
BY
I FIRE DAMAGE (Anyone fire)
.
I MED EXP (Anyone person)
WAIVER:
N/A I .......----~ES
i ! COMBINED SINGLE LIMIT
W '
~ JiBODILYINJURY
:::7~rson)
~'....,..--- "-I-~DILYINJURY
(Per accident)
1$
DATE
;$
I
:$
PROPERTY DAMAGE $
GARAGE lIABIlITY
ANY AUTO
AUTO ONLY - EA ACCIDENT i $
! OTHER THAN AUTO ONLY:
EACH ACCIDENT $
AGGREGATE $
EACH OCCURRENCE ! $
AGGREGATE ~ $
,$
EXCESS UABIUTY
UMBRELLA FORM
i OTHER THAN UMBRELLA FORM
i WORKERS COMPENSATION AND
! EMPLOYERS' LIABIlITY
THE PROPRIETOR!
PAATNERs/EXECUTIVE
OFFICERS ARE:
OTHER
I'Nel i
I EXCL I
Recei ;'Ied!
Risk .~./!i;Int & L,c~;i} C:::;ntf~>1
DATE ---1..:f -'7 ..j '1 Y
---'--"-''1'''-'---'. ,-
INITiAL ~_;;
--~,- ."...--. -~ t' ...._-.. '--....--. -~..
.
.
STATUTOAY LIMITS j
i EACH ACCIDENT ! $
.
: DISEASE - POLICY UMIT ! $
DISEASE. EACH EMPLOYEE : $
!
I
I
I i
" DESCRIPTION OF OPERAllONSlLOCATlONSlVEHIClESISPECIAllTEMS
AIR CONDITIONING SYSTEMS
,
I
CER11FlCATE HOLDER
CANCELLATION
Monroe County Board Of County Commissioners
ATTN: Public Works Division
5100 College Road
Key West, Fl. 33040
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY Will ENDEAVOR TO MAIL
~ DAYS WRrTTEN NOTICE TO THE CERTIFICATE HOLDER NAIlED TO THE lEFT,
BUT FAILURE TO MAIL SUCH NoncE SHAlL IMPOSE NO OBUGAllON OR UABllITY
.. _ OF Atfr-.K1ND UPON TIlE r..-L..alll'llo. ~ .~ ~~"~~~___
jAUTHORIZEii . IR,I,,~ ~
I -"
EUGENE W WAHLSTROM
. ACORD COllPORA11ON 1993
I I
! ACORD zs.s (31113)
-~
. .
POLICY NUMBER:
AMERICAN ENERGY & SHEET METAL CORP.
09 AL 00 7110.* .
COMMERCIAL GENERAL LIABILITY
r-',
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - FORM A
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization (Additional Insured);
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
PUB. WORKS DIVISION
Bodily Injury and
Property Demage Liability
1,000/1,000
Premium Basis
Location of
Covered Operetions
UPPER KEYS FACILITIES
Advance Premium
Cost
N/A
Rates
(Per
$1000 of cost)
Total Adv~hie Premium
$ INCLUDED
$ INCLUDED
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement.1
1. WHO IS AN INSURED (Section III is
amended to include as an insured the person
or organization Icalled "additional insured")
shown in the Schedule but only with re-
spect to liability arising out of:
A. "Your work" for the additional insured(s)
at the location designated above, or
B. Acts or omissions of the additional
insuredlsl in connection with their general
supervision of "your work" at the location
shown in the Schedule.
2. With respect to the insurance afforded
these additional insureds, the following addi-
tional provisions apply:
A. None of the exclusions under Coverage
A except exclusions lal. Idl. leI. If!. Ih2),
iiI. and Iml. apply to this insurance.
B. Additional Exclusions. This insurance does
not apply to:
(1) "Bodily injury" or "property damage"
for which the additional are obligated to
pay damages by reason of the assump-
tion of liability in a contract or agree-
ment. This exclusion does not apply to
liability for damages that the additional
insuredlsl would have in the absence of
the contract or agreement.
(2) "Bodily injury" or "property damage"
occurring after:
CG 20 09 11 85
(a) All work on the project (other than
service, maintenance, or repairsl to be
performed by or on behalf of the
additional insured(sl at the site of the
covered operations has been com-
pleted; or
(b) That portion of "your work" out of
which the injury or damage arises has
been put to its intended use by any
person or organization other than an-
other contractor or subcontractor en-
gaged in performing operations for a
principal as a part of the same project.
(3) "Bodily injury" or "property damage"
arising out of any act or omission of the
additional insuredlsl or any of their em-
ployees, other than the general super-
vision work performed for the additional
insuredlsl by you.
(4) "Property damage" to:
(a) Property owned. used or occupied
by or rented to the additional insured(s);
(b) Property in the care. custody, or
control of the additional insuredls) or
over which the additional insuredls) are
for any purpose exercising physical
control; or
(c) "Your work" for the additional
insuredlsl.
Copyright. Insurance Services Qffice, Inc., 1984
o
A"n.t.
~;:;! ~ ., ,
R "QP' "'INIUIWICE'
.. 6 c~~. ~. .... . ~ ,
.,." ......','.........,.. ...../... "0 '0. . .... '0
ISSUE DATE (MM/DO/YY)
11/10/94
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
PRODUCER
GULF INSURANCE ASSOCIATES, INC.
503 MARSHALL ST
CLEARWATER FL
34615
COMPANIES AFFORDING COVERAGE
~~i'i~~NY A
INSURED
COMPANY B
LETTER
AMERICAN ENERGY & SHEET METAL, INC.
101 N.E. 3RO ROAO
HOMESTEAD FL 33030
COMPANY C
LETTER
COMPANY D
LETTER
V'(iJ\!~R'
N 1\ "__.'" y,S
COMPANY E
LETTER
COtSl*_
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN tSSUED 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 1$ SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO
TR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YY) DATE (MMIDD/YY)
LIMITS
GENERAL LIABILITY
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE
OCCUR.
GENERAL AGGREGATE $
PRODUCrs.COMP/OP AGG. $
PERSONAL & ADV. INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MED. EXPENSE (Anyone person) $
OWNER'S & CONTRACTOR'S PROTo
AUTOMOBILE LIABILITY
ANY AUTO
A XX"LL OWNED AUTOS
XX SCHEDULED AUTOS
HIRED AUTOS
XxNON.OWNED AUTOS
GARAGE LIABILITY
COMBINED SINGLE
LIMIT
$
093157925
11/12/94
05/12/95
BODILY INJURY
(Per person)
$
100,000
$ 300,000
$ 50,000
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE
AGGREGATE
$
$
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
/,~&k
STATUTORY LIMITS
EACH ACCIDENT $
DISEASE-POLICY LIMIT $
DISEASE~EACH EMPLOYEE $
OTHER
lA__,____ /.; .~_1'.7~
~-
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAllTEMS
tli!~].
ADDITIONAL INTEREST:
MONROE COUNTY BOARO OF COUNTY
COMMISSIONERS
ATTN: PUBLIC WORKS
5100 COLLEGE ROAD
KEY WEST FL
RM 502
33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL _ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT ILURE T AIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
L1ABILI OF A Y NO U ON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
ACOflO Z5-S (7198)
@ACOADCOIlPORATION 11180
AeOelt.
CERTIFICATE OF INSURANCE
ISSUE DATE (MMfDDfYY)
PRODUCER
GillJF INSURANCE ASSOCIATES, INC.
29811 US HIGHWAY 19 N
CLEIillWI\TER FLORIDA
08/04/95
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
34621
COMPANIES AFFORDING COVERAGE
f~T~~~NY A
NOVA CASUALTY
INSURED
E~T~~NY B
>VINDSOR INSURANCE COMPANY
APP~'O\'FD Y RISK MAN,^GrmNT
~ o,e(c;.
BL _ 0<.-'4 ---m~ eC.~
~ -1'- 1$
AHERICl.N ENERGY SYSTEMS, INC.
101 N E 3RD RD
HOHESTEAD FLORIDA 33030
E~T~~NY C
E~~~~NY 0
E~T~~~NY E
DATE
~ WWrI/' Nj^ vr~
THIS 1$ TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEE'JiJ I$SU~D Tt) iHt:. tN~UHt:lJNAMl::.U Al;:SuVE 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.
co
LTR
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIDDfYY) DATE (MM/DDIYY)
TYPE OF INSURANCE
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X OCCUR. 09AL007110
OWNER'S & CONTRACTOR'S PROT.
4/6/95
4/6/96
B
AUTOMOBft...E LIABILITY
ANY AUTO
ALL OWNED AUTOS
X SCHEDULED AUTOS
X HIRED AUTOS
X NON-OWNED AUTOS
GARAGE LIABILITY
personal injury protection $10,000
3093157925
6/3/95
12/3/95
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
AND
Recelveu
Risk Mgmr. & L(j~s COntrOl
DATE - L
-- -----------
INITIAl -V,~
--/,:",,(L__
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/SPECIAL ITEMS
**ADDITIONI\L INSURED:
LIMITS
GENERAL AGGREGATE s1 ,000,000
PRODUCTS-COM PlOP AGG. s1 ,000,000
PERSONAL & ADV. INJURY $1 ,000,000
EACH OCCURRENCE .1 ,000,000
FIRE DAMAGE (Anyone fire) $ 50,000
MED. EXPENSE (Anyone person) $ 5 , 000
COMBINED SINGLE .
LIMIT
BODILY INJURY . 100,000
(Per person)
BODILY INJURY .
(Per accident) 300,000
PROPERTY DAMAGE . 5,000
EACH OCCURRENCE .
AGGREGATE .
STATUTORY LIMITS
EACH ACCIDENT .
DISEASE-POLICY LIMIT .
DISEASE~EACH EMPLOYEE .
HONROE COUNTY BOARD OF COUNTY COMMISSIONERS/PUB. WORKS DIVISION
5100 COLLEGE RD
KEY WEST FL 33040-
C--'Al"rl(llil
C1!RllFlCATI! HOLDER
HONROE COUNTY
5100 COLLEGE RD
KEY WEST FL
ATTN: RISK MANAGEMENT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY Will ENDEAVOR TO
MAil ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, B AllU TO MAil SUCH NOTICE SHAll IMPOSE NO OBLIGATION OR
L1ABI Y OF Kl 0 UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
33030
ACCIRO ...
ClI.llllllllJ!i-GIIJIl JIL,1UOtJ1_
. .".!~.~'~~!~_OT_,.!!.uranc.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS
CERTIACATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND. EXTEND. OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED
BELOW.
This is to Certify that
Staff Leasing. L.P.. Total Employee Leasing Services.L.P..
Florida Payroll Leasing & Services. L.P. . Staff Leasing. II. L.P..
Staff Leasing III. L.P., and It's Affiliates and Subsidiaries
1301 6th Ave. West. Suite 101
Bradenton FL 34206
Name and
address of
Insured
LIBER1Y~
MUTUAL.
is. at the issue date of this certificate. insured by the Company under the policy(ies) listed below. The insurance afforded by the
listed policy(ies) is subject to all their terms. exclusions and conditions and is not altered by any requirement. term or condition of
any contract or other document with resoect to which this certificate may be issued.
ERTlFlCATE EXP. DATE
TYPE OF POLICY '0 CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
o EXTENDED
lEI POLICY TERM
Coverage Afforded Under we EMPLOYERS LIABILITY
Law of the Following States:
FL.GA,AL,AZ.CO, Bodily Injury By Accident Each
WORKERS CT. ID, IL. IN, KY, 1.000,000. Aodd.m
COMPENSATION 3-1-96 WC1-651-004110-015 LA.MD,MI,MO,MS, Bodily Injury By Disease Policy
NC,NH,NY,OR,PA, 1,000.000. Limit
SC,TN,TX,VA Bodily Injury By Disease Each
1,000.000. Person
GENERAL LIABILITY General Aggregate-Other than Prod/Completed Operations
o CLAIMS MADE AI'PAO\'{D BY ISK MANAGEMENT Products/Completed Operations Aggregate
I RETRO DATE I BY~' ~//L of-Ie;, Bodily Injury and Property Damage Liability Per
(J ~ - J' - /i..$' Ct..t#.K- Occurrence
DATE Personal and Advertising Injury Per Person!
o OCCURRENCE /"YC. Organization
~'~IVFR: N/A Other: I Other:
AUTOMOBILE Each Accident. Single limit -
LIABILITY B. I. and P. D. Combined
DOWNED Each Person
0 NON-OWNED Each Accident or Occurrence
0 HIRED J) :.1. ,,_ Recei;ed Each ACcident or Occurrence
OTHER (,N(7~'-
DATE
INITIAL 5":>
ADDITIONAL COMMENTS Employees leased to : Their Effective Date:
2832 : 07/03/94
AMERICAN ENERGY SYSTEMS, INC.
The above referenced Worker's Compensation policy provides statutory benefits only to employees of the Named Insured(s) on the policy, not
to employees of any other employer.
'IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM. YOU WILL BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED
BEFORE THE CERTIFICATE EXPIRATION DATE. HOWEVER, YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE.
SPECIAL NOTICE - OHIO: ANY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER.
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUlL TV OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS Liberty Mutual
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT Insurance Group
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES
UNTIL AT LEAST ~ DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
CERTIFICATE
HOLDER
MONROE COUNTY/BOARD
ATTN:RISK MGMT DEPT
5100 COLLEGE RD
KEY WEST, L 33040
cc: . S
OF COUNTY C
JOHN SHAHINIAN
AUTHORIZED REPRESENTATIVE
06/06/95
Orlando. FL
OFFICE
DATE ISSUED
This certificate is executed b UBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by Those Companies
as 772R6
..~_~I~I~~~~_cn_I~.ur.nc.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER. THIS
CERTIFICATE IS NOT AN INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED
BELOW.
This is to Certify that
Staff Leasing, L.P.. Total Employee Leasing Serviees,L.P.,
Plorida Payroll Leasing & Services, L.P. , Staff Leasing, II, L.P.,
Staff Leasing III, L.P.. and It's Affiliates and Subsidiaries
l30l 6th Ave. West, Suite 101
Bradenton PL 34206
Name and
address of
Insured
LIBER1Y~
MUTUAL.
is at the issue dale of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the
Ii~ted policy(ies) is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of
an contract or other document with res ect to which this certificate ma be issued.
ERTlFlCATE EXP. DATE
TYPE OF POLICY . 0 CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
o EXTENDED
III POLICY TERM
WORKERS
COMPENSATION
3-1-96
WC1-651-004110-015
Bodily Injury By Accident Each
1,000,000. Accident
Bodily Injury By Disease Policy
1,000,000. Um'
Bodily Injury By Disease Each
1,000,000. PO"","
General Aggregate-Other than Prod/Completed Operations
Coverage Afforded Under WC
Law of the Following States:
FL,GA,AL,AZ,CO,
CT, 10, IL, IN, KY,
LA,MO,MI,MO,MS,
NC,NH,NY,OR,PA,
SC,TN,TX,VA
EMPLOYERS LIABILITY
GENERAL LIABILITY
I RETRO DATE
o OCCURRENCE
Il'(
DATE
I Products/Completed Operations Aggregate
o CLAIMS MADE
dily Injury and Property Damage Liability
Per
Occurrence
Per Person!
Organization
Personal and Advertising Injury
W'!VER:
N
Other:
Other:
AUTOMOBILE
LIABILITY
DOWNED
o NON-OWNED
o HIRED
Each Accident - Single limit -
B. I. and P. D. Combined
Each Person
Each Accident or Occurrence
OTHER
Each Accident or Occurrence
I!.eceived
IS Mgmt. & Loss Control
.;l
e....I;..... Bulb.
DATE
ADDITIONAL COMMENTS Employees leased to :
2832 :
03/01/95
allUJc:U "l.eaSy ". & S8EEl IIn AI. COItP
The above referenced Worker's Compensation policy provides statutory benefits only to employees of the Named Insured(s) on the policy, not
to employees of any other employer.
'IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM, YOU WILL BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED
BEFORE THE CERTIFICATE EXPIRATION DATE. HOWEVER, YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE.
SPECIAL NOTICE - OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS Liberty Mutual
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT Insurance Group
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES
UNTIL AT LEAST .3Q. DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
CERllFICA TE
HOLDER
5100 COt.:lEGE RIl
KEY WEST, fL 33040
JOHN SHAHINIAN
AUTHORIZED REPRESENTATIVE
Orlando, FL
OFFICE
02114195
DATE ISSUED
This cert;f;cate~ by LIBERTY MUTUAL INSURANCE GROUP as ,espects such Insu,aoce as is afforded by Those Compo"les
cc: -:: S"Q....(T~'L
BS 772R6
CERTIFICATE OF INSURANCE: AMERI-3
PRODUCER
The Johnsons Insurance Agency
89015 Qverseas Highway
Tavern~er FL 33070
305-852-9247
CSR SC 05 09 96
THIS CERTIFICATE IS ISSUED AS A MATTER DF INFORMATION ONLY AND
CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE
DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
POLICIES BELOW.
~._----------------------------------------------------------------
------------------------------------------------------------------.
COMPANY
A Bankers Insurance Company
COMPANIES AFFORDING COVERAGE
-------------------------------------------------------------
INSURED
> COVERAGES <.ma.................................................................................................................
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.
COMPANY
----~---~::~~::~~_~~~_~e~~~_~~~_~~~_______________________
COMPANY II isk ~lt. & Loss Control
----~--------i3^',.------:-c:~:_~~___
COMDPANY A-. J
INITIAL ~
---------------------
erican Energy Systems Inc.
om Viergutz
POB 901295
omestead FL 33090
CO
LTR
---------------------------------------------------------------------------------------------------------------------------------
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFF POLICY EXP
DATE (""/DD/YY) DATE(HH/DD/YY)
LIMITS
------------------------------- --------------------------- --------------- -------------- ----------------------------------
GENERAL LIABILITY
tX] COIlERCIAL GEN LIABILITY
[ ] CLAIMS MADE [Xl occ.
] OWNERS'S & CONTRACTOR'S
PROTECTI VE
]
]
09-5100948-00
04/06/96 04/06/97
GENERAL AGGREGATE 1,000,00
PROD-COMP/OP AGG. 1,000,00
PERS. & ADV. INJURY 1,000,00
EACH OCCURRENCE 1 , 000 , 00
FIRE DAMAGE
(ANY ONE FIRE)
MED. EXPENSE
(ANY ONE PERSON)
------------------------------- --------------------------- --------------- -------------- ------------------- --------------
50,000
5,000
AUTOMOBILE LIABILITY
B [ ] ANY AUTO
[ ] ALL OWNED AUTOS
tX] SCHEDULED AUTOS
[ ] HIRED AUTOS
[ ] NON-OWNED AUTOS
[ ]
[ ]
071912990
03/27/96 03/27/97
COMB. SINGLE LIMIT
BODILY INJURY
(PER PERSON) 100000
BODILY INJURY
(PER ACCIDENT)
300000
GARAGE LIABILITY
[ ] ANY AUTO
[ ]
[ ]
,Appprwrn R\ R!~k'\ ',(f, "~rr~lq)T
----------~~---------- --~------------ -------------- ------------------- --------------
py---~~ 0 1(';
[\nF___~J' . J~__ c i;.
PROPERTY DAMAGE
50000
--- -------------------------------
------------------------------- ------------------------- --------------- -------------- ------------------- --------------
AUTO ONLY (EA ACC)
OTHER / AUTO ONLY:
EACH ACCIDENT
AGGREGATE
EXCESS LIABILITY
[ ] UMBRELLA FORM
[ ] OTHER THAN UMBRELLA FORM
~'.!:,:~:~o. ~~f} __ YES
EACH OCCURRENCE
AGGREGATE
------------------------------- --------------------------- --------------- -------------- ------------------- --------------
WORKERS COMPo AND EMP. LIAB.
THE PROPRIETOR/PARTNERS/
EXECUTIVE OFFICERS ARE:
[ ] INCL. [ ] EXCL.
OTHER
--------------------------- --------------- -------------- ----------------------------------
]STATUTORY LIMITS
EACH ACCIDENT
DISEASE-POL. LIMIT
DISEASE-EACH EMP.
-------------------------------
~DI~R~~~~t;~~~~~~L~~~~;r~~~~/~~i>~i'~E;~~j;iC~;;;;i-i;;~1t~i-i--------------------------.------_____________
1983 Ford Econo E251FDJE37G1DHA49009
1981 Ford Econo E252FTEE24E1BBA06643
onroe County RiSk Management
onroe County Board of Comm.
5100 COllege Road
ey West FL 33040
onroe County is an Additional Insured under these POlicies.
> CERTIFICATE HOLDER <=Z===:======:===========:::_=:_=:.==> CANCELLATION c=.._==_======..====.:===_====:===_==_=====_==_=.=======
MONRO-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO HAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FA 0 IL SUCH NOTICE SHALL E NO OBLIGATION OR.
LIABILIT ANY KI ON THE COMPANY,ITS AGE TS REPRESENTATI~.
Pam
ACORD 25-S (3/93)
- cc:~S'~
PLEASE READ YOUR POLICY POLICY NUMBER CA 0-71-Q 1 - 2QQ-O
This deC~Br8tion~._e1geIAmended Declaration pege with the policy jacket identified by the form and edition date ind'icate1! comlfllftes the
above numoe: 'd :cy.
Pre."Olll .. ,Ji"cy no. Form 1050 Ed. 1194
*** :ri.,S. AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 05/09/96 ***
OECLARA T IONS
NAMED INSURED
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 1 OF 3
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
I NSURED AS STATED HERE I N
FROM MAR 27, 1996 TO MAR 27, 1997
ENDORSED EFFECTIVE:
JUN 10, 1996
33052
/lIT1JlIPnW companier
CA-27757
PROGRESSIVE AMERICAN INS. CD.
P.O. BOX 94739, CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such end so many of the following coverages 8S are indicated with respect to each described
vehicle. The limit of the company's liability against 88Ch such coverage shall be as stated herein, subject to all the terms of this policy
h.v'ng ,efe'ence the,eto. SCHEDULE OF COVERAGES AND LIMITS OF LIABILITY
COVERAGES
A BODILY INJURY LIABILITY
FULL TERM PREMIUM CHARGES
$2097
1100,000 EACH PERSON
300,000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50,000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10,000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS COMP
I UN/UNDERINS MOTORIST-REJECTED
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
$220
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
ON APPLICATION
1100,000 EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
1100,000 EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
NUMBER OF EMPLOYEES (0-10)
$93
$56
FILING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (11-88) 1891 (11-94) 2068 (06-95)
$50.00
$642.00
$2,516.00
DRIVERS PAGE
GAR ADDRESS PAGE
2
3
, COVERED VEH
PAGE ~
APPROVED BY RISK M~N !.GEMENT
BY, <-Kd: ~ ~
f!'TE f?r 3& -'7? PUC-N OTH-N
TR: Nil, /,yrS,_ ".-elt> C~
Any loss under P8~ I I
Fin. Resp. Fi1r3 AE 1
is payable 8S interest may appear to named insured and above loss payee: ProQ.. Premium Bu~t: 4
961"7 f"fW'GY 1 0.0 CA I CS 11 em No, R.Q79, %F.cto, u".79. 5
Countersigned:
By
Authorized Representative
1113 (5-88)
ADDITIONAL INTEREST COpy
CVFL0714940023E1113All
Cc
if?S~
PLEASE READ YOUR POLICY POLICY NUMBERCA Q-71-cll-2QQ-Q
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date incl'icate'd com",lfte~tjle
above numbered policy. ~o~ tI
Previous policy no. Form 1050 Ed. 1194 .I~
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 05/09/96 ***.
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 2 OF 3
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
I NSURED AS STATED HERE I N
FROM MAR 27, 1996 TO MAR 27. 1997
ENDORSED EFFECTIVE:
J UN 10, 1 996
33052
progreoi/e companier
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739, CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so m8ny of the following coverages 8S are indicated with respect to each described
vehicle. The limit of the company's liability against each such coverage shall be 8S stated herein, subject to all the terms of this policy
having reference thereto. SCHEDULE OF DR IVERS
DVR
NO DRIVER NAME LICENSE #
01-01 MANUEL A
02-02 THOMAS
DIANA
MALDONADO
0500541531730
M435820570190
VIOL/ACC SR22 STA
DOB ABC 0 MSC REQ TUS
05/13/53 0 0 0 0 00 N M
01/19/57 0 0 0 0 00 N M
Any loss under Part. I I
Fin. Resp. Filed:
C3
is payeble as interest may eppear to named insured and above loss payee: ProQ.. Premium Bu~t:
AE 1 96~07 3'hfFi'GY 10.0 CA I CS 11 eas. No, R1i\79:> %"0'0' u...79. 45
Counters i gned:
By
Authorized Representative
1113 (5-88)
CVFL00101287Lll13.A2
Pl.EASE READ YOUR POLICY POlrCY NUMBEACA Q-71-Ql-2qQ-Q
This decl.srations ,Page/Amended Declaration page with the pOlicy jacket identified by the form and edition date ind'icate'd comp'l{tes the
above numbered policy.
Prc;,'1io_.~ ~po'i'lcy no. Form 1050 Ed. 1194
*** ~"lS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY
101 NE 3RD ROAD
HOMESTEAD
& SHEET ME
FL 33030
EFFECTIVE 05/09/96
PAGE 3 OF 3
***
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
JUN 10. 1996
33052
progreJ:li/e CDI11panier
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insun!lnce afforded is only with respect to such and so many 01 the following cover8ges 8S are indicated with respect to each described
vehicle. The limit 01 the company's liability against eech such coverage shall be 8S stated herein, subject to all the terms of this pOlicy
hav;nO ,efe,en,e the'eto. SCHEDULE OF COVERED VEH I CLES
VEH DR
NO NO
1-01 2
2-02 99
3-03 1
TRADE
YR NAME
83 FORD
81 FORD
82 DODGE
BODY
TYPE
CARGO/CMPCT
CARGO/CMPCT
VAN
SERIAL NO
lFDJE3lG1DHA49009
2FTEE2 E1BBAOG643
2B7GB13E7CK140894
DVR VEH TER
SCH CLS NO ZIP
5 s06 96 33070
10 s06 96 33070
s06 96 33070
RAD DSC DSC
IUS COD PCT
100 983 30
100 983 30
100 983 30
LIABILITY PREMIUM BY VEHICLE
VEH
NO
1
2
3
BI/PD
~699
m~
MED
PAY
UM/UIM
PIP
~~l
$]1
PHYSICAL DAMAGE PREMIUM BY VEHICLE
VEH COMP OR FT/CAC
NO TYPE OED
1
2
3
PREM
COLLISION
OED PREM
ON-HOOK
LIMIT OED
PREM
VEH
TOTAL
~~6~
$737
III
CT
0,1,9~p'em;um BUdoe7.9.45
R/R %Factor Used:
Any loss under Part is pa.,Y.!l,ble 8S interest may appear to named insured and above loss payee:
F;n, Resp, FU.kJ AE 1 9b,y lvJ;~,GY 1 u. 0 CA I CS 11lC... No,
Countersigned;
By
Authorized Representative
1113 (5-88)
CVFL00101287L1113.A3
PLEASE READ YOUR POLICY POLICY NUMBERCA 0-71-Ql-2QQ-Q
This dec'arations rage/Amended Declaration page with the policy jacket identified by the form and edition date ind'ic8tetl com~ttes the
above numt:oeretj policy.
Pre>>jo~s pOlicy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 05/09/96 ***
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 1 OF 3
A
G JOHNSONS INS AGCY
E PO BOX 2346
~ MARATHON SHORES FL 33052
profllP.oi/e compsnier
POlicy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
J UN 10. 1 996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance 8fforded is only with respect to such and so meny of the following coverages as are indicsted with respect to each described
vehicle. The limit of the company's liability against eech such coverage shall be 8S stated herein, subject to all the terms of this pOlicy
hev;'9 ,.f".",. 'h"eto. SCHEDULE OF COVERAGES AND L I M I TS OF L I AB I L I TY
COVERAGES
A BODILY INJURY LIABILITY
FULL TERM PREMIUM CHARGES
$2097
1100.000 EACH PERSON
300.000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50.000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10.000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS COMP
I UN/UNDERINS MOTORIST-REJECTED
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
$220
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
ON APPLI CAli ON
1100.000 EACH PERSON
300.000 EACH ACC.
50.000 EACH ACC.
1100.000 EACH PERSON
300.000 EACH ACC.
50.000 EACH ACC.
NUMBER OF EMPLOYEES (0-10)
$93
$56
FILING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (11-88) 1891 (11-94) 2068 (06-95)
$50.00
$642.00
$2.516.00
OR I VERS PAGE
GAR ADDRESS PAGE
2
3
. COVERED VEH PAGE
3
PUC-N
OTH-N
Any loss under Pari. I I
Fin. Resp. Fil1::d) AE 1
is payable as interest may appear to named insured and above loss payee: Pro~ Premium BuGJ;t: 4
96'10] 3'~W'GY 10.0 CA I CS 11 em No, R1il79:. %Fec'o' uoe.79. 5
Countersigned:
By
Authorized Representative
1113 (5-88)
ADDITIONAL INTEREST COPY
CVFL0714940023E 1113A 11
PLEASE READ YOUR POLICY POLICY NUMBERCA Q-71-Ql-2qQ-Q ~
This declarations Page/Amended Declaration page with the pOlicy jacket identified by the form and edition date ind'icate'd coml1llftes'the
above numbered policy.
Previous policy no. Form 1050 Ed. 1194 '"
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 05/09/96 ***
AMERICAN ENERGY & SHEET ME PAGE 2 OF 3
DECLARATIONS 101 NE 3RD ROAD
NAMED INSURED HOMESTEAD FL 33030
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
POlicy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
JUN 10. 1996
33052
Pl'DgreuW CDtnPilnier
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so m8ny of the following coverages as are indicated with respect to each described
vehicle. The limit of the compeny's liability against each such coverege shall be 8S stated herein, subject to all the terms of this policy
".v;ng "'".n,, '"".'0. SCHEDULE OF DR IVERS
DVR
NO DRIVER NAME LICENSE #
0500541531730
M435820570190
DOB
VIOL/ACC SR22 STA
ABC 0 MSC REQ TUS
01-01 MANUEL A
02-02 THOMAS
DIANA
MALDONADO
05/13/53 0 0 0 0
01/19/57 0 0 0 0
00
00
N
N
M
M
Any Joss under parlt I I
Fin. Resp. Filed:
C3 AEl
is payable liS interest may appear to named insured and above loss peyee: ProQ. Premium Bu'J;t:
96FIO~3W"gm'G S C." No, R!;l79~ %Foo'o, u,"d79. 45
I ~K Y 10.0 CAlC I1C
Countersigned:
By
Authorized Representative
1113 (5-88)
CVFL00101287Lll13.A2
PLEASE READ YOl.lR POLICY POLICY NUMBERCA Q-71-Ql-2qQ-Q
This dec~arations Page/Amended Declaration page with the policy jacket identified by the form end edition date in~cate1! com~lftes the
above numbereJ pOlicy.
Pre~_Jious foi;cy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY
101 NE 3RD ROAD
HOMESTEAD
& SHEET ME
FL 33030
EFFECTIVE 05/09/96
PAGE 3 OF 3
***
A
G
E
N
T
JOHN SONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN
FROM MAR 27, 1996 TO MAR 27, 1997
ENDORSED EFFECTIVE:
JUN 10, 1996
33052
progre.uile comP8l1ier
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739, CLEVELAND, OHIO 44101
1-800-444-4487
The insurence afforded is only with respect to such end so many of the fOllowing coverages 8$ are indicated with respect to each described
vehicle. The limit of the company's liability 8gainst each such coverage shall be 8$ stated herein, subject to all the terms of this policy
hev;n. 'ef.,ence the'eto. SCHEDULE OF COVERED VEH I CLES
VEH
NO
DR TRADE
NO YR NAME
BODY
TYPE
SERIAL NO
DVR VEH TER RAD DSC DSC
SCH CLS NO ZIP IUS COD PCT
5 s06 96 33070 100 983 30
10 s06 96 33070 100 983 30
s06 96 33070 100 983 30
1-01 2
2-02 99
3-03 1
83 FORD
81 FORD
82 DODGE
CARGO/CMPCT lFDJE3lG1DHA49009
CARGO/CMPCT 2FTEE2 E1BBA06643
VAN 2B7GB13E7CK140894
LIABILITY PREMIUM BY VEHICLE
VEH
NO
1
2
3
BI/PD
~699
sUi
MED
PAY
UM/UIM
PIP
~~i
$]1
PHYSICAL DAMAGE PREMIUM BY VEHICLE
VEH COMP OR FT/CAC
NO TYPE OED
1
2
3
PREM
COLLI S I ON
OED PREM
ON-HOOK
LIMIT OED
PREM
VEH
TOTAL
~A6~
S737
III CT
Any loss under PlIrt is pllIlllble liS interest mllY IIp'pellr to nllmed insured and lIbove loss plIyee; Ot'r9jiPremium BUdge19. 45
F;n. Re.p. Fn&.3 AE 1 9b~J lv~~GY 1 u. 0 CA I CS 111(,... No, RJR %Fecto, U..d,
Countersigned:
By
Authorized Representlltive
1113 (5-88)
CVFL00101287L1113.A3
-_M_~M~_"_..___ "'.____..
. .
progreDl/e companle.r
ADDITIONAL INSURED
The person or organization named below is a person insured with respect to such liability coverage
as is afforded by the policy but this insurance applies to said insured only as a person liable for
the conduct of another insured and then only to the extent of that liability. We also agree with you
that insurance provided by this agreement will be excess insurance over any other valid and
collectible insurance.
NAME OF PERSON OR ORGANIZATION:
MONROE CTY BO COMM
5100 COLLEGE RO
KEY WEST
FL 33040
All other parts of this policy remain unchanged.
This endorsement changes Policy No.: 0 - 7191299 - 0
Issued to (Name of Insured): AMERICAN ENERGY & SHEET ME
Endorsement Effective: 03/27/9a Expiration: 03/27/97
Form No. 1 198 (8-93)
CVFL0624940043Ll198021
. .
progreDl/e companler
ADDITIONAL INSURED
The person or organization named below is a person insured with respect to such liability coverage
as is afforded by the policy but this insurance applies to said insured only as a person liable for
the conduct of another insured and then only to the extent of that liability. We also agree with you
that insurance provided by this agreement will be excess insurance over any other valid and
collectible insurance.
NAME OF PERSON OR ORGANIZATION:
IIONROE CNTY BD OF C
5100 COLLEGE RO
KEY WEST
FL 33040
P.cc~~, ,r,
y;
(;[,t;-ol
9-13 "l?
..---......--..
_"Pft
All other parts of this policy remain unchanged.
This endorsement changes Policy No.: 0 - 7191299 - 0
Issued to (Name of Insured): AMERICAN ENERGY & SHEET ME
Endorsement Effective: 03/27/98 Expiration: 03/27/97
Form No. 1 198 (8-93) CVFl0624940043l11980 1 r
'---~-~~'-"'-'-"
PLEASE READ YQU:q POLICY POLICY NUMBERCA Q-71-Q 1-2QQ-O
This declaration" Page/Amended Declaration page with the pOlicy jacket identified by the form and edition date incficate"l! commttes the
abQve llumbin.ad policy.
- Prev~ous policy no. Form 1050 Ed. 1194
***,THIS -AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 06/10/96 ***
DEClARA T IONS
NAMED INSURED
A
G JOHNSONS INS AGCY
E PO BOX 2346
~ MARATHON SHORES FL 33052
progre.oi/e COmpi1nier
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 1 OF 3
Policy period 12;01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN
FROM MAR 27. 1996 TO MAR 27, 1997
ENDORSED EFFECTIVE:
J UN 1 7. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739, CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as afe indicated with respect to each described
vehicle. The limit of the company's liability against each such coverage shalf be as stated herein, subject to all the terms of this policy
h,,'opefe,eo'''he,e,o, SCHEDULE OF COVERAGES AND LIMITS OF LIABILITY
~100.000 EACH PERSON
300,000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50,000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10,000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS COMP
, UN/UNDERINS MOTORIST-REJECTED ON APPLICATION
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
COVERAGES
A BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
VEHICLE 04 ADDED
FULL TERM PREMIUM CHARGES
$3865
$283
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
NUMBER OF EMPLOYEES (91-100)
$93
$560
F I LING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (J 1-88) 1891 (J 1-94) 2068 (06-95)
DR'VERS PAGE
LOSS PAYEE PAGE
2
4
, COVERED VEH PAGE
3
.'f'<i:U
Loss Com;rol
...q>- /~-=J?t:: __
?9!1______
$50.00
$ 1,811.00
$4,851.00
APPROVED BY RISK MANI,GEMfNT
BY I? - /6 -;/'/
DATE ~=/'~.L
(/
N/^_ ~VF~ ______n____
ct2.' G>'
C,All'>y
,S-MY~
PUC-N
OTH-N
\yr,'\!FR
Any loss under par\ I I is payable as interest may appear to named insured and above loss payee:
Flo, Re,p, FI'(;.3 AE 1 96)"79'h~~GY 1 0.0 CA I CS 11 C'm No
Countersigned:
1113 (5-88)
_."'_"_'^"_"n~"',__
Pro$. Premium BU~t;
R1il79:> %F."o, u,e.77 .53
By
ADDlT I aNAL I NTEREST COPY
Authorized Representative
CVFL0714940023E 11 1 3AI 1
PLEASE READ YOUR POLICY POLICY NUMBEACA Q-71-Ql-2QQ-Q'
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date ind'icatetl coml1llftes th",
above numbered policy.
Previous policy no. Form 1 050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 06/10/96 ***
DECLARA T I QNS
NAMED INSURED
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 2 OF 3
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN
FROM MAR 27. 1996 TO MAR 27, 1997
ENDORSED EFFECTIVE:
JUN 17. 1996
33052
progre.oi/e compsnier
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739, CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as are indicated with respect to each described
vehicle. The limit of the company's liability against each such coverage shall be as stated herein, subject to all the terms of this policy
having reference thereto. SCHEDULE OF DR IVERS
DVR
NO DRIVER NAME
01-01 MANUEL A
02-02 THOMAS
DIANA
MALDONADO
LICENSE #
0500541531730
M435820570190
DOB
VIOL/ACC SR22 STA
ABC 0 MSC REQ TUS
05/13/53 0 0 0 0 00 N
01/19/57 0 0 0 0 00 N
M
M
h. '''':v'''''' ...3
,. .j.., ~. '.' .'.':~
' . ,.".,.. ..,....~..,~~,.. ,>;t ""-~. .
! ..- -..-.."""
L
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Any loss under parlt , I
"n. R.,p. "''(;.3 AE 1 96~o79wh~R'GY
is payable as interest may appear to named insured and above loss payee: Pro~ Premium Bu~t:
Case No: R.Q79? %Factor used77 .53
10.0 CAICS11C
Counters i gned:
By
Authorized Representative
1113 (5-88)
CVFL00101287L1113.A2
PLEASE READ YOU~ POLICY POLICY NUMBER CA Q-71-Q 1- 2QQ-O
This declaration>.; Page/Amended Declaration page with the policy jacket identified by the form and edition date ind'icated comr1lttes the
above !;,umber(;!d policy.
Previous pill icy no. Form 1050 Ed. 1194
***~HIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY
101 NE 3RD ROAD
HOMESTEAD
& SHEET ME
FL 33030
EFFECTIVE 06/10/96
PAGE 3 OF 3
***
A
G JOHNSONS INS AGCY
E PO BOX 2346
~ MARATHON SHORES FL 33052
progre.oi/e companier
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
JUN 17. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. DHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as are indicated with respect to each described
vehicle. The limit of the company's liability against each such coverage shall be as stated herein, subject to all the terms of this policy
h..;ng ,efe,en,e the,.to. SCHEDULE OF COVERED VEH I CLES
VEH DR TRADE
NO NO YR NAME
1-01 1 83 FORD
2-02 99 81 FORD
~=g~ 99 82 DODGE
2 88 CHEVROLET
BODY
TYPE
CARGO/CMPCT
CARGO/CMPCT
VAN
STRAIGHT TK
SERIAL NO
lFDJE37G1DHA49009
2FTEE24E1BBAOb643
2B7GB13E7CK140894
2GBHG31K6J4130017
DVR VEH TER RAD DSC DSC
SCH CLS NO ZIP IUS COD PCT
s06 96 33070
10 s06 96 33070
10 s06 96 33070
5 c40 96 33070
100
100
100
100
983 30
983 30
983 30
000
LIABILITY PREMIUM BY VEHICLE
VEH MED
NO BI/PD PAY UM/UIM PIP
1 1666 r
2 732 76
~ 732 Zg
$1.735
PHYSICAL DAMAGE PREMIUM BY VEHICLE
VEH COMP OR FT /CAC COLLISION ON-HOOK VEH
NO TYPE DED PREM DED PREM LIMIT DED PREM TOTAL
1 1~6~
2
~ 808
$1.795
III
CT
Oi,9,liP,em;"m B"dge77 .53
RIR %Factor Used:
Any loss under Part is pa"yable as interest may ap'pear to named insured and above loss payee:
F;n. R.,p. F;I&,3 AE 1 9b~J~J;~,GY 1 u. 0 CA I cs 11lC... No,
Countersigned:
By
Authorized Representative
1113 (5-88)
CVFL00101287L1113.A3
.
.
progreDl/e compi/Oler
ADDITIONAL INSURED
The person or organization named below is a person insured with respect to such liability coverage
as is afforded by the policy but this insurance applies to said insured only as a person liable for
the conduct of another insured and then only to the extent of that liability. We also agree with you
that insurance provided by this agreement will be excess insurance over any other valid and
collectible insurance.
NAME OF PERSON OR ORGANIZATION:
MONROE CTY 90 COMM
5100 COLLEGE RO
KEY WEST
FL 33040
All other parts of this policy remain unchanged.
This endorsement changes Policy No.: 0 - 7191299 - 0
Issued to (Name of Insured): AMERICAN ENERGY & SHEET ME
Endorsement Effective: 03/27/96
Expiration: 03/27/97
Form No. 1 198 (8-93)
CVFL0624940043L 1198021
PLEASE READ YOUR POLICY POLICY NUMBER CA 0-71-q 1-29q-0 ~
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date indicated completes the aoave num'bered policy.
Previous policy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 06/17/96 ***
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL 33052
PROGREJJ//IE@
{: AMERICAN ENERGY & SHEET ME
?11 ~g~E~ia~D ROAD FL 33030
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27, 199 TO MAR 27, 1997
ENDORSED EFFECTIVE:
AUG 15, 1996
PAGE 1 OF 3
DECLARATIONS
NAMED INSURED
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739, CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as are indicated with respect to each described vehicle. The limit of
the company's liability against e~'CH'~'i\'U'e~ral'f\:'h~'~~R'A'llrS'erRy:j'D,u'r"fkt~f'sth'O\!,r"[' fA'/lij E~i'i"Y'aving reference thereto
FULL TERM PREMIUM CHARGES
$4464
COVERAGES
A BODILY INJURY LIABILITY
~100'OOO EACH PERSON
300,000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50,000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10,000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS COMP
I UN/UNDERINS MOTORIST-REJECTED ON APPLICATION
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
$354
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
NUMBER OF EMPLOYEES (91-100)
$93
$560
VEHICLE
CHANGED
FILING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (11-88) 1891 (11-94) 2068 (06-95)
$50.00
$412.00
$5,521.00
DRIVERS
PAGE
2
, COVERED VEH PAGE
3
APPROVED BY RISK MI,N4GlMENT
BY~d~
['\TF 7'-3~?~
/.~c
dR I C;
C C-bT"e/~
PUC-N
DTH-N
~f)
N/,~
Any loss under Part I I I is payable as interest may appear to named insured and above loss payee:
Fin Resp File(b AF 1 96~o7<fhERGY 10.0 CA I CS 11 (ase No,
Prog Premium Budget: CT
RJilJ95 %Factor uSed61 .36
Countersigned C c .' /i7 ' s;., ~<' <-J
Form No. 1113 (12-92) ADDITIONAL INTEREST COpy
Authorized Representative
CVFLD126964205L111301A
PLEASE READ YOUR POLICY . POLICY NUMBER C A 0 -7 1 - q 1 - 2 9 q - 0
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date indicated completes the above numbered policy.
Previous pOlicy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 06/17/96 ***
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 2 OF 3
A
G
E
N
T
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
AUG 15. 1996
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL 33052
PROGRE.JJlVE@
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as are indicated with respect to each described vehicle. The limit of
the company's liabifity against each such coverage Shall~eA~ti~te'(5i~, 8fj~erVf~lsthe terms of this policy having reference thereto.
DVR VIOL/ACC SR22 STA
NO DRIVER NAME LICENSE # DOB ABC D MSC REQ TUS
01-01 MANUEL A DIANA D500541531730 05/13/53 0 0 0 0 00 N M
02-02 THOMAS MALOONADO M435820570190 01/19/57 0 0 0 0 00 N M
03-03 LARRY MCCOLLISTER M242537510130 01/31/51 0 0 0 0 00 N S
Any loss under Part I I I is payable as interest may appear to named insured and above 1055 payee:
F;n Resp. F;let3 AF 1 96~o7thERGY 10.0 CA I CS 11 [ese No
Prog Premium BUdget CT
RW95 %Factor UsedP 1.36
Countersigned:
By
Authorized Representative
Form No. 1113 (12-92)
ADDITIONAL INTEREST COPY
CVFL0126964205L111302A
~=
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0_
0=
0............
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0-
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-
.=
PLEASE READ YOUR POLICY POLICY NUMBER C A 0 -7 1 - q 1 - 2 9 q - 0
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date indicated completes the aoave numoered policy.
Previous policy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY
101 NE 3RD ROAD
HOMESTEAD
& SHEET ME
FL 33030
EFFECTIVE 06/17/96
PAGE 3 OF 3
***
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL 33052
PROGREJ:rIVE@
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
AUG 15. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as ate indicated with respect to each described vehicle. The limit of
the company's liability against each such covera~~'d'OE!st'8~ hcrotrElt~1Jt Xtf~trt~~ of this policy having reference thereto.
VEH DR TRADE BODY DVR VEH TER RAD DSC DSC
NO NO YR NAME TYPE SERIAL NO SCH CLS NO ZIP I US COD PCT
1-01 3 83 FORD CARGO/CMPCT 1FDJE3lG1DHA4~009 s06 96 33070 100 983 30
2-02 99 81 FORD CARGO/CMPCT 2FTEE2 E1BBAO 643 10 s06 96 33070 100 983 30
~=g~ 1 g~ CHEVY VAN 1CCDM15Z5JB147777 s06 96 33070 100 983 30
2 CHEVROLET STRAIGHT TK 2GBHG~IK6J413001l 5 c40 96 33070 100 000
5-06 99 89 PLYMOUTH VOYAGER lP4FH 432KX60922 10 S09 96 33070 100 983 30
LIABILITY PREMIUM BY VEHICLE
VEH MED
NO BI/PD PAY UM/UIM PIP
1 1666 r
2 ~2t 76
~ ~6
SISU~
5 76
PHYSICAL DAMAGE PREMIUM BY VEHICLE
VEH COMP OR FT/CAC COLLISION ON-HOOK VEH
NO TYPE OED PREM DED PREM LIMIT OED PREM TOTAL
1 1~6~
2
~ 737
SlS~~~
5
Any loss under Part I I I is payable as interest, may appear to named insured and above loss payee:
F;nResp.F;le~3 AFl 96~o7IfhERGY 10.0 CAICS11(aseNO
Prog Premium Budget: CT
R~795 %Factor Used61 .36
Countersigned:
By
Authorized Representative
Form No. 1113 (12-92)
ADDITIONAL INTEREST COPY
CVFL0126964205L111303A
PROGREJJlVE@
ADDITIONAL INSURED
The person or organization named below is a person insured with respect to such liability coverage as is afforded
by the policy but this insurance applies to said insured only as a person liable for the conduct of another insured and
then only to the extent of that liability. We also agree with you that insurance provided by this agreement will be
excess insurance over any other valid and collectible insurance.
NAME OF PERSON OR ORGANIZATION:
MONROE CNTY SO OF C
5100 COLLEGE RD
KEY WEST
FL 33040
All other parts of this policy remain unchanged.
This endorsement changes Policy No.: 07191299-0
Issued to (Name of Insured): AMERICAN ENERGY & SHEET ME
Endorsement Effective: 03/27/96 Expiration: 03/27/97
Form No. 1198 (8-93)
CVFL0124961607L119801
-
-
-
---
-
::::::::::::
~
==
-
==
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0==
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PROGREmVE@
PROGRESSIVE
PO BOX 94739
CLEVELAND OH 44101
04365
1"11",11,11,,,,1,,111,,,,1,,1,,11,,,,111,1,,11,,,11,,,,,11,1
MONROE CNTY BD OF C
5100 COLLEGE RD
KEY WEST FL 33040
'I.....".,~'"-ck''f}
a~.. .7-...........
"j ~....
If you have any questions on the enclosed documents, please call Progressive. Be prepared to specify the
policy type (Auto, Motorcycle, etc.), state and policy number.
BNRFOLDL
PMFL0126960000BNRFOLDL
FROM: $-$;&5
PHONE NO. : 3052480013
Oct. 07 1995 11:33RM P02
7trrJ'26'26
.
STATE OJfFLORIDA
Department of Bueln..a and Prof,sslonal Regulation
CONST INDUSTRY LICENSING BOARD
fIiIff"l,Jl"Jr-------------- __n ---,,"',-- .-...-------
09/04/199 96901048 CA .C051517
~-_._--_.. -..---..--------.--.---".. .... .......-....
n. CLASS 8 All CONDITIONING CONTRACTOR
.....lIIlft IS C E T If IE D
WlllIIt "'-"""' II ar.ter 48 9 . FS.
hlIlll1lot1 dill: AU II "31. 1 99 8
.-...~.......~----
I!II'Hli'E~~IG~I\~I~~MS
,71 CAIA CT
TAVERN ER FL
INC
33070
LAWTON CKlLES
GOVERNOR
DISPLAY AS REQUIRED BY LAW
RICHARD T. FARRELL
SECRETART
, . . .,' '. ". '..~,:". "
DO NOT FORWAlID
'MFRfCAN EN~R;Y & SHEETMETAl CO
TOM YIERGUll
P 0 Bale 901295
HOMESTF.AD FL 33090
1"11.,.11.11",1,1,.11",,"11..1,11.1,.,1,1.1,\,,,1.1..1,,11
=ASEREADYOURPOLlCY POLlCYNUMBERCA 0-71-Q]-29Q-0
s declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date indicated completes the Boave numoered policy.
Previous policy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 08/15/96 ***
DECLARA liONS
NAMED INSURED
A
G
E
N
T
JOHN SONS INS AGCY
PO BOX 2346
MARATHON SHORES FL 33052
PROGREmvE@
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE ] OF 3
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27, 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
SEP 17. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following cQverages as are indicated with respect to each described vehicle. The limit of
the company's liability against ~'Clf~'i\'U'efaffi:"h~I~~'R~'llrS'erA~u'u~'fhtYf'sth'b\!,r"E fA'/l'l E~Wavlng reference thereto
FULL TERM PREMIUM CHARGES
$5196
~100'OOO EACH PERSON
300,000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50,000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10.000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS COMP
I UN/UNDERINS MOTORIST-REJECTED ON APPLICATION
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
COVERAGES
A BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
$430
~lOO'OOO EACH PERSON
300,000 EACH ACC.
50.000 EACH ACC.
~100'OOO EACH PERSON
300,000 EACH ACC.
50.000 EACH ACC.
NUMBER OF EMPLOYEES (91-100)
$93
$560
$50.00
$423.00
$6.329.00
FILING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (11-88) 1891 (11-94) 2068 (06-95)
DRIVERS
. COVERED VEH PAGE 3
APPROVFD BY RISK MANA,GfMFNT
,
RY~~~'
PATE /6 -.;2/-7~
PAGE
2
~ C/~~~
l>DC-N OTH-N
""'[R: NlA ~YFS.~
Any loss under Part I I I is payable as interest may appear to named insured and above loss payee:
FlnResp,Flle13 AEl 96~'!\7'hAMER 10.0 CAICS11l~;aseNo:
Prog Premium Budget: CT
RW95 %Factor used52. 32
Countersigned:
cc~ ~ S~
Authorized Representative
Form No. 1113 (12-92)
ADDITIONAL INTEREST COPY
CVFL0126964205L 111301 A
PLEASE READ YOUR POLICY. POLICY NUMBER CA 0-71-Q 1- 29Q-0
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date indicated completes the soove numoered policy.
Previous policy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 08/15/96 ***
DECLARATIONS
NAMED INSURED
A
G
E
N
T
JDHNSONS INS AGCY
PD BOX 2346
MARATHON SHORES FL 33052
PROGREDlVE@
PAGE 2 OF 3
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
SEP 17. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as are indicated with respect to each described vehicle. The limit of
the company's liability against each such coverage Sh811~eAt.ti1ir~etBir' ~'ilerVf~lsthe terms of this policy having reference thereto.
DVR VIOL/ACC SR22 STA
NO DRIVER NAME LICENSE # DOB ABC D MSC REQ TUS
01-01 MANUEL A
02-02 THOMAS
03-03 LARRY
DIANA
MALDONADO
MCCOLL I STER
D500541531730
M435820570190
M242537510130
05/13/53 0 0 0 0 00 N
01/19/57 0 0 0 0 00 N
01/31/51 0 0 0 0 00 N
M
M
S
Any loss under Part I I I is payable as interest may appear to named insured and above loss payee:
F;n. Resp. F;le~3 AE 1 96i~7hAMER 10 _ 0 CA I CS 11 Ease No
Prog Premium Budget: CT
RW95 %Factm Used52. 32
Countersigned:
Form No. 1113 (12-92)
By
Authorized Representative
ADDITIONAL INTEREST COPY
CVFL0126964205L111302A
;;;;;;;;
-
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-
-
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I EASE RSiD YOUR POLICY POLICY NUMBER CA. 0-71-q 1- 29Q-0
1 is declarations Page/Amended Declaration page with the policy jacket identjfied by the form and edition date indicated completes the soave numoered policy.
Previous policy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY
101 NE 3RD ROAD
HOMESTEAD
& SHEET ME
FL 33030
EFFECTIVE 08/15/96
PAGE 3 OF 3
***
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL 33052
PROGRHJ/I/E@
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
SEP 17. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the foHowing coverages as Bre indicated with respect to each described vehicle. The limit of
the company's liability against each such covera~CfI~I~eIst~1? hcroi(rEl:t~1)t ~~~trtr~ of this policy having reference thereto.
VEH DR TRADE BODY DVR VEH TER RAD DSC DSC
NO NO YR NAME TYPE SERIAL NO SCH CLS NO ZIP IUS COD PCT
1-01 99 83 FORD CARGO/CMPCT lFDJE3lG1DHA4~009 10 s06 96 33070 100 983 30
2-02 99 81 FORD CARGO/CMPCT 2FTEE2 E1BBAO 643 10 s06 96 33070 100 983 30
2=g~ 3 S~ CHEVY VAN lCCOM15Z~JB147777 s06 96 33070 100 983 30
2 CHEVROLET STRAIGHT TK 2GBHG21K J413OO1l 5 c40 96 33070 100 000
~-06 99 89 PLYMOUTH VOYAGER lP4FH 422KX60922 10 S09 96 33070 100 983 30
-07 1 71 FORD 3/4T 4X2 PU F25YRUO 962 S55 96 33070 100 983 30
LIABILITY PREMIUM BY VEHICLE
VEH MED
NO BI/PD PAY UM/UIM PIP
1 r32 r
2 U~ 76
2 ~6
$l~U5
~ 66~ 76
71
PHYSICAL DAMAGE PREMIUM BY VEHICLE
VEH COMP OR FT/CAC COLLISION ON-HOOK VEH
NO TYPE DED PREM DEO PREM LIMIT DED PREM TOTAL
1 ~808
2 808
2 737
$1~~~1
~
737
Any loss under Part I I I is payable as interest may appear to named insured and above loss payee:
F;n.ReSPF;!e~3 AEl 96~(lH"hAMER 10.0 CAICS11CaseNo,
Prog Premium Budget: CT
~95 %Factor used52. 32
Countersigned:
By
Authorized Representative
Form No. 1113 (12-92)
ADDITIONAL INTEREST COpy
CVFL0126964205L111303A
PROGREIllVE@
ADDITIONAL INSURED
The person or organization named below is a person insured with respect to such liability coverage as is afforded
by the policy but this insurance applies to said insured only as a person liable for the conduct of another insured and
then only to the extent of that liability. We also agree with you that insurance provided by this agreement will be
excess insurance over any other valid and collectible insurance.
NAME OF PERSON OR ORGANIZATION:
MONROE CNTY BO OF C
5100 COLLEGE RO
KEY WEST
FL 33040
All other parts of this policy remain unchanged.
This endorsement changes Policy No.: 07191299-0
Issued to (Name of Insured): AMERICAN ENERGY & SHEET ME
Endorsement Effective: 03/27/96 Expiration: 03/27/97
Form No. 1198 (8-93)
CVFL0124961607L119801
..........
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PROGR6.fIVE@
PROGRESSIVE
PO BOX 94739
CLEVELAND DH 44101
05427
1"11."11.11.,,,1.,111,.,,1,.1.,11.,,.111.1,,11.,,11,.".11,1
MONROE CNTY BD OF C
5100 COLLEGE RD
KEY WEST FL 33040
If you have any questions on the enclosed documents, please call Progressive. Be prepared to specify the
policy type (Auto, Motorcycle, etc.), state and policy number.
~<. :x:e! 'Ii eel
BNRFOLDL
PMFL0126960000BNRFOLDL
Certificate of Insurance
, TIIIS CEI<:fIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER THIS CERTIFICATE IS NOT
AN INSURANCE POLICY AND OOES NOT AMEND, EXTEND, OR ALTER TI-IE COVERAGE AFFORDED BYTI-IE POLICIES LISTED BELOW.
This Is to Certify that
I Staff Leasing, L.P., Staff Leasing II, L.P., Staff
Leasing III, L.P., Staff Leasing, IV, L.P. Staff
Leasing V, L.P.
600 301 Blvd. West Suite 202
I Bradenton, FL 34205 ~
Is. at lI1e Issue date of II1Is cerlWlcale, insured by tI1a Company under lI1e policy(ies) listed below. The insurance afforded by lI1e listed poIicy(ies) Is subjaclto all tI1air
tenno, exclusions and conditions and is not altsned by any requirement, tenn or condition 01 any contract or otI1er doaJment with respect to which tI1Is ceriWlcate may be
~~
Name and
address of
Insured.
LIBER1Y~
MUTUAL~
"
issued.
0 EXP.DATE
CONTINUOUS
TYPE OF POLICY 0 EXTENDED POLICY NUMBER LIMIT OF LIABILITY
ex POLICY TERM
COVERAGE AFFORDED UNDER WC EMPLOYERS UABIL/TY
LAW OF THE FOLLOWING STATES:
01/01/97 WA 1-650-004110-296 AL, AZ, CA, CT, DE, Bodily IrjUlY By Accident
WORKERS $1,000,000 Each
COMPENSATION FL, GA, IL, lA, IN, KY, Accident
LA, MO, MI, MN, MS, Bodily Injury By Disease
MO, NC, NE, NH, OK, $1,000,000 Policy
Limit
I N'r F'm'fT 8\ R!Sh ~.~ t ',; ,fJcr \1 r_NT PA, SC, TN, TX, UT, Bodily Injury By Disease
i
I ..-<t/. 'V1 >~l' VA $1,000,000 Each
Per3>:il'l
.. ()3- General Aggregate - Other lI1an Proc:lJclsICompleted Opemlions
GENERAL :/ - 7tf.
LIABILITY D^TE
o OCCURRENCE N/A. / ProductslCornpletsd 0peralI0ns Aggregele
W,,'l,rFR: YES
D CLAIMS MADE Bodily Injury and Property Damage liability Per
Occurrence
Personal Injury
I RETRO DATE I Per Personl
Organization
Other Other
AUTOMOBILE Each _nt - Single UmR
LIABILITY BJ. and P.O. CoImIned
OWNED Each Person
NON-OWNED Each Accident or Oocunence
HIRED Each Accident or Oocunence
OTHER .
I.~~~~~~e~::~~-~o: ---~----- I .. - ------- --. ------~ .-----. "-~~~-----~----~-
AMERICAN ENERGY SYSTEMS, INC. 2832 Effective Date: 713/94
The above referenced Workers' Compensation policy provides statutory benefits only to employees of the Named Insured(s) on the policy,
not to employees of any other employer.
. if the certificate expiration date is continuous or extended term. you 'NtH be notified If coverage is terminated or reduced before the certlflcate expiration dat..
SPECIAL NOTICE-OHIO: ANY PERSON WHO, WITH IN'TENT TO DEFRAUD OR KNOWtNB THAT HE IS FACIUTATING A FRAUD AGAINST AN INSURER. SUBMITS
AN APPlICATION OR FILES A ClAIM CONTAWING A FALSE OR DECEPTIVE STA'TCMENT IS GUlL lY OF INSURANCE FRAUD.
NOTICE OF CAf'I""IlII 611OM: (NOT APPlICABLE UNLESS A NUMBER OF DAYS IS EN'TERED BELOW.) BEFORE
THE STATKt EXPIRATION DATE THE COMPANY WILL NOT CANCa OR REDUCE THE INSURANCE AFFORDED
UNDER THE ABOVE POUCIES UNTIL AT LEAST 30 DAYS
NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
I
~~ COUNTY OF MONROE
HCUlER PUBLIC WORKS DIVIPUBLIC FACILITIES MAIN.
3583 SOUTH ROOSEVELT BLVD
L'<EY WEST FL
Liberty Mutual Group
5081
/~~
Linda Mielke
AUTHORIZED REPRESENTATIVE
ORLANOO,FL
2/23/96
33040
~
OFFICE
DATE ISSUED
This certificate is cx&uted by LIBERTY MUTUAL GROUP as respects such insurance as is afforded by Those Companies
BS 772L (FL)
PLEASE ~READ YOUR POLICY POLICY NUMBERCA 0-71 -Q 1- 2qQ-Q
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition dete ind'ic8te1!l coml1lttes the
above numbered policy.
Previous p~licy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 05/09/96 ***
DECLARATIONS
NAMED INSURED
AMER1 CA-N ENE"RGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 1 OF 3
/
A
G
E
N
T
33052
progre.oi/e companier
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27, 199 TO MAR 27, 1997
ENDORSED EFFECTIVE:
MAY 9, 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739, CLEVELAND, OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages as are indicated with respect to each described
vehicle. The limit of the comp8ny's li8bility against each such coverage shall be 8S st8ted herein, subject to all the terms of this policy
hav;n9 ,efe,ence the'eto. SCHEDULE OF COVERAGES AND LIMITS OF LIABILITY
COVERAGES
A BODILY INJURY LIABILITY
FULL TERM PREMIUM CHARGES
$1365
~100'OOO EACH PERSON
300,000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50,000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10,000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS CDMP
I UN/UNDERINS MOTORIST-REJECTED
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
$144
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
ON APPL I CAT! ON
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
NUMBER OF EMPLOYEES (0-10)
$93
$56
FILING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (11-88) 1891 (11-94) 2068 (06-95)
$50.00
$25.00
$1,708.00
DRIVERS PAGE
LOSS PAYEE PAGE
2
3
, COVERED VEH PAGE 3
APPROVED BY RISK W~',GEMENT
BY ~ ~ Q"t(/e.
~ / e~.
PI'lE ...::%- t~__ PUC-N
OTH-N
'''', ''-p.
~',~
~wc
Any loss under parlt I I is payable as interest may appear to named insured and above loss payee: Prall-. Premium Bu~J;b
F;n. Re,p. FHoe'3 AEl 96~07t"f~!GY 10.0 CAICS11eeee No! R1i\79, %Fa"o, ",e",,8.21
1113 (5.88)
cc: _S~
ReCeIVed
l<iSk Ivlgmt. & Loss ConrffiPITIONAL INTEREST COPY
'f - -q, .'
DAT'_'_-"--:~L) -
~I:dl; Ih! __.._._.___....:: __..._.._..__........e...__
CVFL0714940023E1 1 1 3A 11
Countersigned:
PLEASE READ YOUR POLICY POLICY NUMBERCA Q-71-Ql-2qQ-Q
This declarations Page/Amended Declaration page with the policy jacket identified by the form 8nd edition C1ete ind'icate'd coml1l{tes the
above numbered policy.
Previous policy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE EFFECTIVE 05/09/96 ***
DECLARATIONS
NAMED INSURED
A
G
E
N
T
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
33052
progre.r.rile compilnier
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 2 OF 3
Policy period 12;01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
MAY 9. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages 8S are indicated with respect to each described
vehicle. The limit of the company's liability against each such coverage shall be 8S stated herein, subject to all the terms of this policy
having reference thereto. SCHEDULE OF DRIVERS
DVR
NO DRIVER NAME
01-01 MANUEL A DIANA
02-02 THOMAS MALDONADO
Any loss under parll I I
F;n. Rup. Fded) AE 1 96iOjrh~~'GY
LICENSE #
0500541531730
M435820570190
VIOL/ACC SR22 STA
DOB ABC 0 MSC REQ TUS
05/13/53 0 0 0 0 00 N M
01/19/57 0 0 0 0 00 N M
is payable as interest may appear to named insured and above loss payee:
Case No:
10.0 CAICS11C
prolJ. Premium BU~l;
R1il79:> %F.o<o, u...,o8. 21
Countersigned:
1113 (5-88)
By
Authorized Representative
CVFL00101287L1113.A2
PLEASE'READ YOUR POLICY POLICY NUMBERCA 0-71-Ql-2QQ-Q
This declarations Page/Amended Declaration page with the policy jacket identified by the form and edition date ind'icatetl comp'llftes the
above numbered policy.
Previous pOlicy no. Form 1050 Ed. 1194
*** THIS AMENDED DECLARATIDN SUPERSEDES PRIDR DECLARATIDN PAGE
DECLARATIONS
NAMED INSURED
AMERICAN ENERGY
101 NE 3RD ROAD
HOMESTEAD
& SHEET ME
FL 33030
EFFECTIVE 05/09/96
PAGE 3 OF 3
***
A
G
E
N
T
JOHN SONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN
FROM MAR 27. 1996 TO MAR 27. 1997
ENDORSED EFFECTIVE:
MAY 9. 1996
33052
progre.oi/e compilnier
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101
1-800-444-4487
The insurance afforded is only with respect to such and so many of the following coverages 8S are indicated with respect to 98Ch described
vehicle. The limit of the company's liability against each such coverage shall be as stated herein, subject to all the terms of this poticy
heving ,.f.,.n,. th"eto. SCHEDULE OF COVERED VEH I CLES
VEH
NO
DR TRADE
NO YR NAME
BODY
TYPE
SERIAL NO
DVR VEH TER RAD DSC DSC
SCH CLS NO ZIP IUS COD PCT
5 s06 96 33070 100 983 30
s06 96 33070 100 983 30
1-01 2 83 FORD
2-02 I 8 I FORD
CARGO/CMPCT 1FDJE3lG1DHA49009
CARGO/CMPCT 2FTEE2 E1BBAOG643
LIABILITY PREMIUM BY VEHICLE
VEH
NO
1
2
BI/PD
MED
PAY
UM/UIM
PIP
~~~~
$73
$71
PHYSICAL DAMAGE PREMIUM BY VEHICLE
VEH COMP OR FT/CAC
NO TYPE DED
I
2
PREM
COLLISION
DED PREM
ON-HOOK
LIMIT DED
PREM
VEH
TOTAL
$772
$737
III
CT
0,7,9,lip"m;,m B"dgee8. 21
RIR %Factor Used:
Any loss under Part is palable as interest may appear to named insured and above loss payee:
Fin. "..p. FiI&J AE1 9b~J:WJ;~GY 10.0 CAICS111C... No,
Countersigned:
By
Authorized Representative
1113 (5-88)
CVFLOOIOI287LII13.A3
PLEASE REAO YOUR POLICY POLICY NUMBERCA 0-71-QI-2Qq-0
This declarations PIge/Amended Declaration page with the policy jacket Identified by the form and eclition date ind'icete'd com~'t.. the
above nll~.r.d ~~Iicy. 4
. Pr.: .0:15 llollcy no. Form 1050 Ed. 119
*** '.TH I S AMENDED DECLARATI ON SUPERSEDES PR lOR DECLARATI ON PAGE EF FECTI VE 05/09/96 ***
OECLARA T IONS
NAMED INSURED
AMERICAN ENERGY & SHEET ME
101 NE 3RD ROAD
HOMESTEAD FL 33030
PAGE 1 OF 3
A
G
E
N
T
33052
progrE'.DW compi1l1ier
JOHNSONS INS AGCY
PO BOX 2346
MARATHON SHORES FL
Policy periOd 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM MAR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
JUN 10. 1996
CA-27757
PROGRESSIVE AMERICAN INS. CO.
P.O. BOX 94739. CLEVELAND. OHIO 44101 1-800-444-4487
The insurance afforded Is only with r..pect to such and so many of the following coyerag.. "'a. ar. indicated "";'ith r..pect to each de.cribed
vehicla. The limit of the company'. liability against each such coverage shall ba as atated herein, subject to all the terms of this pOlicy
.oy;n. ,ofo,.n.. '.""00 SCHEDULE OF COVERAGES AND LIMITS OF LIABILITY
COVERAGES 0
A BODILY INJURY LIABILITY ~100.000 EACH PERSON
300.000 EACH ACC.
B PROPERTY DAMAGE LIABILITY 50.000 EACH ACC.
BASIC PERSONAL INJURY PROTECTION $10,000 LIMIT/PERS.
LESS NO OED. PER PERSON FOR NAMED INSURED
WITH WORKERS COMP
I UN/UNDERINS MOTORIST-REJECTED
HIRED AUTO LIABILITY
BODILY INJURY LIABILITY
FULL TERM PREMIUM CHARGES
$2097
$220
PROPERTY DAMAGE LIABILITY
NON-OWNED AUTO LIABILITY
BODILY INJURY LIABILITY
PROPERTY DAMAGE LIABILITY
ON APPLI CAT I ON
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
~100'OOO EACH PERSON
300,000 EACH ACC.
50,000 EACH ACC.
NUMBER OF EMPLOYEES (0-10)
$93
$56
FILING FEES
TOT. CHARGES DUE TO CHANGE
TOTAL TERM PREMIUM
ATTACHMENT IDENTIFIED BY FORM NUMBER
1198 (08-93) 1652 (06-95) 1890 (11-88) 1891 (11-94) 2068 (06-95)
$50.00
$642.00
$2.516.00
DRIVERS PAGE
GAR ADDRESS PAGE
2
3
. COVERED VEH PAGE
3
,
PUC-N
OTH-N
Any loss un.der P.r\ I I is payable .. inter..t may. appear to named insured and above 10.. pay..: Proi- Premium eu~t 4
FinoR.oPoFllt) AEl 96i~3""fW'Gy 10.0 CAICSlleo..NO, R1il79, %Fo.'o,u..dl9. 5
Countersigned:
By
Authorized Repr.sentative
1113 (5.88)
ADDITIONAL INTEREST COpy
CVFLD71494Q023E1113All
PLEASE READ YOUR POLICY POLICY NUMBERCA Q-71-QI-2QQ-0
This dad.ratlons Pege/Amended Declaration page with the policy jacket identified by the form and edition aate Inctlcate'd com~"'t.s the
above numbered P;Olicy.
Pr.~"iollS f"l~cy no. Form 1050 Ed. 1194
*** THIS A"'ENDED DECLARATION SUPERSEDES PRIOR DECLARATION PAGE
DECLARATIONS
NAMED INSURED
A"'ERICAN ENERGY
101 NE 3RD ROAD
HO"'ESTEAD
& SHEET "'E
FL 33030
EFFECTIVE 05/09/96
PAGE 3 OF 3
***
A
G
E
N
T
33052
progI'E'.UW companier
JOHNSONS INS AGCY
PO BOX 2346
"'ARATHON SHORES FL
Policy period 12:01 A.M. STANDARD TIME AT THE ADDRESS OF THE NAMED
INSURED AS STATED HEREIN 6
FROM "'AR 27. 199 TO MAR 27. 1997
ENDORSED EFFECTIVE:
JUN 10, 1996
CA-27757
PROGRESSIVE A"'ERICAN INS. CO.
P.O. BOX 94739. CLEVELAND, OHIO 44101 1-800-444-4487
The insurance afforded Is only with respect to such and so many of the following coverag.. "as are indicated with r..pect to each d.scribed
vehicle. The limit of the company's liability against .ach such coverage shall be as stated herein, subject to all the terms of this policy
hav;n. r.f.r.nc. th.r.to. SCHEDULE OF COVERED VEH I CLES
VEH DR
NO NO
1-01 2
2-02 99
3-03 1
TRADE
YR NA"'E
83 FORD
81 FORD
82 DODGE
BODY
TYPE SERIAL NO
CARGO/C"'PCT lFDJE3lG1DHA49009
CARGO/C"'PCT 2FTEE2 E1BBA06643
VAN 2B7GB13E7CK140894
DVR VEH TER
SCH CLS NO ZIP
5 S06 96 33070
10 S06 96 33070
s06 96 33070
RAD DSC DSC
IUS COD PCT
100 983 30
100 983 30
100 983 30
LIABILITY PRE"'IUM BY VEHICLE
VEH
NO
1
2
3
BI/PD
~699
~lU
"'ED
PAY
U"'/UI'"
PIP
~~~
$71
PHYSICAL DA"'AGE PRE"'IU'" BY VEHICLE
VEH CO"'P OR FT/CAC
NO TYPE OED
1
2
3
PREM
COLLI S I ON
OED PRE'"
ON-HOOK
LI MIT OED
PRE'"
VEH
TOTAL
~~~~
~737
;
III
CT
ia p.,l,ble a. Inter.st may ap'pe.r to named insured and above los. pay..: Oi'r9j)Premlum BUdg.1.9.45
9l)PoIlv..tlGY lu.O CAICS11ICa.. No, RIR %Factor U...,
Any 10.. under Part
F;n. R.... FIl.!;,3 AE 1
Countefslgned:
By
Authorized Repr...ntetive
1113 (5-88)
CVFL00101287L1113.A3
.
.
progreD7/e companler
ADDITIONAL INSURED
The person or organization named below is a person insured with respect to such liability coverage
as is afforded by the policy but this insurance applies to said insured only as a person liable for
the conduct of another insured and then only to the extent of that liability. We also agree with you
that insurance provided by this agreement will be excess insurance over any other valid and
collectible insurance.
NAME OF PERSON OR ORGANIZATION:
MONROE CNTY Bo OF C
5100 COLLEGE Ro
KEY WEST
FL 33040
All other parts of this policy remain unchanged.
This endorsement changes Policy No.: 0 - 7191299 - 0
Issued to (Name of Insured): AMERICAN ENERGY & SHEET ME
Endorsement Effective: 03/27/9B Expiration: 03/27/97
Form No. 1198 (8-93)
CVFL0624940043L 1 1980 11
AlA '+.L';) L 0 L 0 ::; tAl CUI- I-LUHIUA,
Department of Business and Professional Regulation
CONST INDUSTRY LICENSING BOARD
LI ENR "
96901048 CA -C051517
_"".__n_'_~... __ ___.,__...____.._.______
The CLASS B AIR CONDITIONING CONTRACTOR
Named below IS CERTIFIED
Under the provtslons of Cha~er 4 8 9 , FS,
Expiration date: AU G 31. 1 9 9 8
VIERGUTZ. TOM WILLIAM
AMERICAN ENERGY SYSTEMS INC
179 CAU CT
TAVERNIER FL 33070
LAIITON CHILES
GOVERNOR
DISPLAY AS REQUIRED BY LAW
RICHARD T. FARRELL
SECRETARY
~~~,~~,,~~{;c,.,
~;\'if4'..TIJ( COLUaro.to,
. ~~.... ~4Q W.'~&n.1
ii- i1th'..co:o;."
~\ ~ 30
,',' i.'fl~ .
, '. . ....."....."'~.1.n"'........"..'.~ J'll'."''''''".1'"'
3039-'2~~8;~:,5-:,;,:*~;~f,k~:>;~.;.)t?~tf:' ,
" .,.BUSINESS" NAME,/LOCAnON ;~,,-~,~,~,;.t'c:\~~i~~ '"
'.",'~AMER.ICAN~ENE~&j~.oJHlif
..r,101.iNEJa;.,RI)o~.t>t~\," . -;"~"',~fi:(i:i!"
,,'339,30ictlJl"J:STEAD,'i. . .,,';"j~;l~~~.r~'~fl'
'-'(:!"~r.,'/, ':;:<::,:-:',' ':"'~":;0~.i,":, ,~'JJt:~"';'i,~~' _ ,~ '~;~',J~~i-;;t t <~,' ~_'
~MEiN(: AN{'E~E~~~,i 'StJEET';igiKL(;E~{i
::'_S8c.~Ot Bwl....: ',::>..~:' _: ',: . '_::: - '...,.,'>.<:\:\.~~:/:~i...:t~".
. "~ 96 . SeEl;.'.~_~H'(~':11~C!i~N I~AI,.;c';i~N.:;'1,,'~
~=~ ..l,,;'_~~r.'J>~.~~';':,'~":"~ . "'<;>:.' :'~:~.-:.~":,:;\:~l~\f~f<~k~' .
VlOLA1I:.,"ANY" EXI81lNO
REClULATORY,Ofl;.ZONI<<l.
;=~=.~)~.~
VCDIPT."!'-lHE'":', LlClNII!I
"FROII MfY 01'HU LICIHSE '
.l,OR~,REQUIW) BY":
iLAw.,11tII.~~NOT"A.,~:\
~FlCAnoN '~~~~M'ATrfTHir:.
'.,LJCEH8EE'I{!i.1'\~ _,
'~4il~Jr~~;t;;S,
.. ,."./08:/.0.1]..96. .,.,
:"<156994001',,,
'00003'1~5~ .
DO NOT FORWARD
~MERICAN ENeRGY ~ SHEETMETAL
TOM VIERGUTl
POBOX 901:295
HOMESTEAD fl 33090
co
\"II",IIIII",I,II,II"I."II"I.II,I",I,I.I,I,"I,l,,1,,11
seE OTHER SIDE
Certificate of Insurance Received
THIS CERTIFICATE [5 ISSUED AS A MAlTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE H;.QLDER,. )'H15 CEE.TlrCATE~NkF I
AN INSURANCE POLICY AND OOES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES USTED BELO~)Sk Mgmt. &. ass n ro
~-
Name and
address of
Insured.
tfB
MUTUAL.
This Is to Certify that
I Staff Leasing, L.P., Staff Leasing II, L.P., Staff
Leasing III, L.P., Staff Leasing, IV, L.P. Staff
Leasing V, L.P.
600 301 Blvd. West Suite 202
I Bradenton, FL 34205 ~
Is, at the Issue date of this certificate, insUled by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(les) Is subject to all their
terms, exclusions and cooditlons and Is not altered by any requirement, tenn or condition of any contract or other dooument with respect to which this certificate may be
issued
DATE
I
10 EXP.DATE
CONTINUOUS
TYPE OF POLICY iD EXTENDED POLICY NUMBER LIMIT OF LIABILITY
!~ POLICY TERM
COVERAGE AFFORDED UNDER WC EMPLOYERS UABIUTY
LAW OF THE FOLLOWING STATES,
01/01/97 WA 1-650-004110-296 AL, AZ, CA, CT, DE, Bodily IrjulY By Accident
WORKERS $1,000,000 Each
COMPENSATION FL, GA, IL, lA, IN, KY, Accident
LA, MO, MI, MN, MS, Bodily In~1Y By Disease
MO, NC, NE, NH, OK, $1,000,000 POlicy
limit
PA, SC, TN, TX, UT, Bodily InjulY By Disease
VA $1.000,000 Each
Person
GENERAL Aprrpn\' ty' PI," ""."C,F"FNT Aii. [2eneral Aggregate - Other than F'roDJds/CompIe Operations
LIABILITY BY _ '--'1 7/7/'// c' !C-
D OCCURRENCE ,/1,~ ~ ProductslCompieted Operations Aggregate
Cj;-~~-7~
D 'CLAIMS MADE DATE Bodily InjulY and Properly Damage Llabillly
~ES Per
WAIVER: N/A Occurrence
Personal Injury Per Person!
IRETRO DATE I Organization
Other Other
AUTOMOBILE Each Accident - Single Um~
LIABILITY B.I. and P.O. Corrili\ed
OWNED Each Person
NON-OWNED Each _ant or Occurrence
HIRED Each Accident or Occurrence
OTHER
,
ADDITIONAL COMMENTS
Employees Leased To: AMEl'lICAN ENERGY SYSTEMS, INC. 2632 Effective Date: 7/3/94
The above referenced Workers' Compensation polley provides statutory beneins only to employees of the Named Insured(s) on the polley,
not to employees of any other employer.
. If the certtftcate expiration date ls condnuous or extended term, you wll be notified" coverage 18 terminated or reduced before the cerlificate expiration date.
8PECIAL NOTICE-OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNCM'ING "J1oIAT ME IS FACILITATING A FRAUD AGAINST AN INSUREA, SUBMITS
AN APPLICATION OR FLEe A CLAIM CONTAINING A FAlSE OR DECEPTlVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE OF CAWClI!!I unON: (NOT APPLICABLE UNLESS A NUMBER OF DAYS.s ENTERED ss..ow,) BEFORE Liberty Mutual Group
THE STATED EXPlRA110N DATE THE COMPANY WH..L NOT CANCEL OR REDUCe THE fNSURANCE AFFORDED ~
UNDER THE ASOVE POlJCIES UNTIL AT LEAST 30 DAYS . l ~
N01lCEOF~CANCELLATJONHASBEENMAlLEDTO: ., /AAd/lo "7/// /' /7
I 5081 V"KA-q
CERlFlCATE MONROE COUNTYIBOARD OF COUNTY
HOlDER 5100 COLLEGE RD
Linda Mielke
AUTHORIZED REPRESENTATIVE
~EY WEST
CC ~
s;
FL
33040
~
ORLANOO,FL
OFFICE
2/23/96
DATE ISSUED
This certificate is executed by LI
AL GROD s respects such insurance as is afforded by Those Companies
BS 772L (FL)
Certificate of Insurance
THIS CERTlFICA IE IS ISSUED AS A MA TIER OF INFORMA nON ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICA IE HOLDER. THIS CERTIFICA IE IS NOT
AN INSURANCE POLICY AND roES NOT AMEND, EXTEND, OR ALTER THE COVERAGE AFFORDED BY THE POLICIES LISTED BELOW
This is to Certi that
Staff Leasing, L.P., Staff Leasing II, L.P., Staff
Leasing III, L.P., Staff Leasing, IV, L.P., Staff
Leasing V, L.P.
600 301 Boulevard West, Suite 202
Bradenton, Florida 34205
is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the
listed policy(ies) is subject to all their terms, exclusions and conditions and is not aitered by any requirement, term or condition of
an contract or other document with res ect to which this certificate ma be issued.
CERTIFICATE EXP. DATE
. D CONTINUOUS
D EXTENDED
IXI POLICY TERM
J-.\\ i6
Name and
address of
Insured
TYPE OF POLICY
POLICY NUMBER
WORKERS
COMPENSATION
1-1-98
WA 1-65D-00411 0-297
GENERAL LIABILITY
o CLAIMS MADE
I RETRO DATE I
o OCCURRENCE
BY
',\TE
AUTOMOBILE
LIABILITY
DOWNED
o NON-OWNED
o HIRED
;/"d/. 7
'J(f?
OTHER
/
LIBERTI '-
MUTUAL~
LIMIT OF LIABILITY
Covemge Affocded Unde, WC EMPLOYERS LIABILITY
Law of the Following Slales:
AL, AR, AZ, CA, CO, CT, Bodily Injury By Accident Each
DE, DC, FL, GA, lA, IL, IN $1,000,000. Accident
KY, LA, MA, MD, ME, MI, Bodily Injury By Disease Policy
MN, MS, MO, NC, NE $1,000,000. Limit
NH, NM, NJ, NY, OK, PA, Bodily Injury By Disease Each
RI, SC, TN, TX, UT, VA $1,000,000. Person
General Aggregate.Other than Prod/Completed Operations
Products/Completed Operations Aggregate
Bodily Injury and Property Damage Liability
Per
Occurrence
Per Person/
Organization
Personal and Advertising Injury
Other:
Olher:
Each Accident. Single Limit -
B.1. and P.O. Combined
Each Person
Each Accident or Occurrence
Each Accident or Occurrence
Errj-2JE~S LEASED TO: EFFE~l}~~~~7
R"'ERICRN ENERGY SYSTE"'S, INC.
The above referenced Workers' Compensation policy provides statutory benefits only to employees of the Named Insured(s) on the: policy, not
to employees of any other employer.
"IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM, YOU WILL BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED
BEFORE THE CERTIFICATE EXPIRATION DATE. HOWEVER, YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE.
SPECIAL NOTICE - OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A I~UMBER OF DAYS IS
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES
UNTIL AT LEAST 30 DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILEO TO:
Liberty Mutual Group
/~~
"'ONROE COUNTY/BORRD OF COUNTY C "''''15. LINDA MIELKE
RTTN: RISK "'RNRGE"'ENT AUTHORIZED REPRESENTATIVE
5100 COLLEGE RD 05/16/97
KEY WEST, FL 33040 Bradenton 800-475-4430
OFFICE PHONE
CERTIFICATE
HOLDER
DATE ISSUED
This certificate is executed by LIBERTY MUTUAL GROUP as respects such insurance as is afforded by Those Companies
t"i
DATE (MMIDDIYY)
04/08/97
THIS CERTIFICATE IS ISSUED AS A MATI'ER OF INFORMATION
ONLY AND CONFERS NO RIGIITS UPON THE CERTIFICATE
HOLDER. TIIlS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
PRODUCER
The Johnsons Insurance Agency
89015 OVerseas Highway
Tavernier FL 33070
PAM CURRY
305-852-9247
INSURED
COMPANY
A
Bankers Insurance Company
..,.,
"7)\?
\ '
COMPANY
B
American Energy Systems Inc
Tom Viergutz
POB 901295
Homestead FL 33030
/
COMPANY
C
COMPANY
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDlCATED, NOlWITIISTANDlNG ANY REQUIREMENT, TERM OR CONDmON OF ANY CONTRACT OR OrnER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECf TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
03/27/97 03/27/98
BODILY INJURY . '00000
(Per person)
BODILY INJURY . 300000
(peraccldent)
PROPERTY DAMAGE . 50000
AUTO ONLY - EA ACCIDENT
OTHER THAN AUTO ONLY:
EACH ACCIDENT .
AGGREGATE .
EACH OCCURRENCE .
AGGREGATE .
.
STATUTORY LIMITS
EACH ACCIDENT .
DISEASE - POLICY LIMIT .
DISEASE - EACH EMPLOYEE .
CO
LTR
POLICY NUMBER
POUCY EFFECTIVE POLICY EXPlRATI
DATE (MMIDDIYY) DATE (MMIDDlYV)
TYPE OF INSURANCE
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY 09510094800
CLAIMS MADE W OCCUR
OWNER'S & CONTRACTOR'S PROT
04/06/97
04/06/98
B
AUTOMOBn..E LIABILITY
ANY AUTO
ALL OWNED AUTOS
X SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AtrrOS
071912990
GARAGE LIABILITY
ANY AtrrO
qy
IT
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILiTY
\'i.:\'ER:
N/A ~ YES
THE PROPRIETOR!
PARTNERSffiXECUTTVE
OFFICERS ARE:
OTHER
INCL
EXCL
DESCRIPTION OF OPEKATIONSILOCATIONSIVEIDCLESISPECIAL ITEMS
air conditioning contractor repair/replace/install
ADDITIONAL INSUREO AS FOLLOWS: MONROE COUNTY BOARD OF COUNTY COMMISSIONERS,
MONROE COUNTY RISK MANAGEMENT, 5100 COLLEGE ROAD, KEY WEST, FL 33040
LlMm
GENERALAGOREGATE
PRODUCTS - COMPfOP AGO
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone fife)
MED EXP (Any one person)
$ 1 000,000
. 1,000 000
$1,000,000
$ 1 000,000
$ 50 000
. 5,000
COMBINED SINGLE LIMIT
.
COUNTY OF MONROE - MONROE
COUNTY RISK MANAGEMENT
5100 COLLEGE ROAD
KEY WEST FL 33040
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEKEOF, THE ISSUING COMPANY WILL ENnEA VOR TO MAIL
-19-- DAYS WRITI'EN NOTICE TO THE CERTlF1CATE HOLDER NAMED TO THE LEFf,
BUT FAILURE TO MAIL SUCH NOTICE SIIALL IMPOSE NO OBLiGATION OR LiABILITY
MONROEC
ACOJll)Z$$ (3IIl:lJ
lvl d~::=t
.,u.". 4". '.: ,n
....,.,.-..., ....-.-..-..-....."...-..-..--.
OF ANY KIND UPON THE COMPANY, ITS AGENI'S OR REPRESENTATIVES.
AUTHORI~~NTAT~
~,~~:::..~,~.~r.:.::.tgXt\...\J.,40.L!)&
. ACOlU! CORi'OJlA1'ION.lm
Certificate of Insurance
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON YOU THE CERTIFICATE HOLDER THIS CERTIFICATE IS NOT AN
INSURANCE POLICY AND DOES NOT AMEND, EXTEND, OR ALTER THE,COVERAGE AFFORDED BY THE I'OLlClE5 LISTED BELOW.
V
IThlS Is to Certify thet
STAFF LEASING, L.P., BY STAFF ACQUISITION, INC"I
THE GENERAL PARTNER, AND THE AFFILIATED
LIMITED PARTNERSHIPS OF WHICH STAFF
ACQUISITION. INC. IS THE GENERAL PARTNER AND
THEIR SUCCESSOR CORPORATIONS
600 301 BOULEVARD WEST, SUITE 202 I
I BRADENTON, FLORIDA 34205 ~
Is. at the issue dale of this certificate, insul8d by the Company under the poIlcy(les) listed below. The insurance aIIoIdad by the listed poIicy(les) is subject to atl their
!8nns, sxclusions and oondltions end is not aIlsl8d by any 19quil8menl, tenn qr condition of any oontJacl or olhsr document wiIh respect io w1iiCh this ceriilica18 mey be
TYPE OF POLICY
CERllFICATE EXP. DATE
D 'CONTINUOUS
D EXTENDED
Di: POLICY TERM
POLICY NUMBER
01/01/99
WA 1-650-004110-298
WC1-651-004110-018
WORKERS
COMPENSATION
GENERAL
LIABILITY
D OCCURRENCE
I RETRO DATE
o CLAIMS MADE
BY
DATE
WAiVER:
AUTOMOBILE
LIABILITY
DOWNED
o NON'()WNED
o HIRED
OTHER
rYt)'.
cc.
Employees Leased To:
8341
I(ft
"l.
lij Name and
~- address of
Insured.
LIBER1Y". :
MUTUAL .
LIMIT OF LIABILITY
COVERAGE AFFORDED UNDER wc
LAW OF THE FOLLOWING STATES:
nerat Aggrege1B -
EMPLOYERS UABILITY
Bodily IrjUlY By Accidsnt
$1,000,000 ~~g~enl
Bodly Injury By Dies...
$' 000 OOC Polley
'" Limit
Bodily Injury By Dies...
$1 000 000 Each
.. Person
rthan PIo<iJctsICompiOlBdOperations
All States Endorsement
ProcIuc:tsICompleted Operations Aggrsgete
Badly Injury and Property Damaga L.iabilly
Po,
Occurrence
Parson" end IIdver1ising Irjury
Per Person/
Organization
Other
Other
I
Each _.Ill . SWlgle Lim~J
B.1. end P.O. Contlinsd
. - I
. . ~
Each Po""",
Each Accidsnt '" Qccurmnc& ;
Each Accident or Occurrence !
Effective Date:
1/1/98
AMERICAN ENERGY SYSTEMS, INC.
The above raterenced WorKers' Compansatlon policy providas a1a1utlry bsnefils only to employeo. of the Named Insul8d(s) on the policy, not to ompbyees of any
other ampIoysr.
'IF lliE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM, YOU WIU. BE NOTIAED IF COVERAGE IS TERMINATED OR REDUCED BEFORE THE CERTIFICATE EXPIRATION
DATE.
SPEcw. NOTICE. OHIO: N4Y PERSON WHO, WfTH INTIiiNT TO DEFRAUD OR KNOWING THAT HE IS FACILrrATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A
CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
IMPORTANT NOTICE TO FLORIDA POUCYHaDERS AND CERT1FfCATE HOlDERS: IN THE EVENT YOU HAVE NN QUESllONS OR NEED INFORMATlON ABOUT TIiIS CERTIFICATE FOR ANY
REASON!.. PlEASE CONTACT YOUR LOCAL SALES PRODUCER. 'MiOSE NM.tE AND TELEPHONE NUMBER APPEARS IN ntE LOWER RIGHT HAND CORNER OF THIS CERTIFICATE. THE
APPAQPHIATE l.OOAl SALES OFFtCE MAILING ADDRESS tD,y ALSO BE OBTAINED BY CALliNG THIS NUMBER.
NOTICE OF CANCB.LA11ON: (NOT APPLICABl.E UNLEsS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE
COMPANY WU. NOT CANCEL OR REDUCE THE INSURANCE AfFOROED UNDER THE ABOVE POLICIEs Liberty Mutual Group
UNTlL AT LEAST 300AYS NOllCE OF SUCH CANCEU.AllON HAS BEEN MAILED TO:
CERTR:AlE
HOlDER
IMONROE COUNTYIBOARD OF COUNTY
RISK MANAGEMENT
5100 C9~LE~.J!Q .SIQCK .ISLAND
~E.Y_w..EST,- f!- .33040
I
A~ta~~" ~
o aid Lynn Houser
AU IZED REPRESENTATIVE
Bradenton, FL 8llO-475-4430 1/1/98
OFFICE PHONE DATE ISSUED
This certificate is executed by LIBERn' MUTUAL GROUP as respects such insurance as is afforded by Those Companies
BS 772L R2
Certificate of Insurance
THIS CERTlFlCATE IS ISSUED AS A .'\.1ATTER OF I'\'FORMATION ONI.Y AND CONFERS NO RIGHTS CPO\: YOU THE CERTIFICATE HOlDER THIS CERTIFICATE 15 ~OT
AN INSURANCE POLICY AND DOES NOT AMEND, EXTFNI), OR AlTER n IE COVERAGE AFFORDED BY THE rOLlCIES LISTED BELOV\".
g)^' ~
I 014 ~ _~
Is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their
terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be
~_Y!l!L___
!
~-
Name and
address of
Insured.
LIBERlYf;
MUTUAL .
This Is to Certify that
I NOVACARE EMPLOYEE SERVICES. INC.
402 43RD STREET WEST
BRADENTON, FL 34209
./
I
TYPE OF POLICY
EXP.DATE
. 0 CONTINUOUS
o EXTENDED
POLICY TERM
POLICY NUMBER
LIMIT OF LIABILITY
WORKERS
COMPENSATION
COVERAGE AFFORDED UNDER we
LAW OF THE FOllOWING STATES:
EMPLOYERS LIABILITY
WC2-631-004155-027
Bodily Injury By Accident
$1,000,000.
Bodily Injury By Disease
$1,000,000.
Bodily Injury By Disease
$1,000,000.
"General Aggregate ~ Other than Products/Completed Operations
ALL STATES EXCEPT STATE
FUND STATES AND THE
STATE OF WI
7/1/2000
(3 yr. Policy)
"W A2-63D-004155-017
WI
GENERAL
LIABILITY
o OCCURRENCE
o CLAIMS MADE
rRETRO DATE
[ ,
!
I
I
AUTOMOBILE
LIABILITY
0 OWNED BY
0 NON-OWNED OHE
0 HIRED W~!VfR:
OTHER
Products/Completed Operations Aggragate
, Bodily Iniurv and Property Damage liability
P.,
Occurrence
I Personallliju,y-
Per Person!
Organization
___L
ADDITIONAL COMMENTS
COVERAGE IS PROVIDED FOR ONLY THOSE EMPLOYE
! AMERICAN ENERGY SYSTEMS INC.
-- --- ------- ~---~
Other Other
_.~------~--- -~--- ---~
Each Accident ~ Single limit
B.I. and P.O. Combined
Each Person
Each Accident or OCcurrence
Each Accident or Occurrence
** WA Policy includes Deductible Endorsement with $100,000 Deductible
Umit per occurrence/claim (disease) with provision that Uberty Mutual
"______~ Wit~~_~~~_nce payment 01 tlie d~~~b1e amount.
0, BUT NOT SUBCONTRACTORS OF:
* If the certificate expiration date is continuous or extended term, you will be notified If coverage is terminated or reduced before the certificate expiration date.
SPECIAL NonCE.oHlo: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS
AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS ENTERED BELOW.) BEFORE
THE STATED EXPIRATION DATE THE COMPANY WILL NOT CANCEL OR REDUCE THE INSURANCE AFFORDED
UNDER THE ABOVE POLICIES UNTIL AT LEAST xx DAYS
NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
!MONROE COUNTY
CERTIFICATE BOARD OF COUNTY RISK MANAGEMENT
HOLDER 5100 COLLEGE ROAD STOCK ISAND
KEY WEST FL 33040
L
3001
Liberty Mutual Group
~OVl' ~.\~
---- _.~-~- --- --------
Helene McBrearty
AUTHORIZED REPRESENTATIVE
if {~f18
Tl"lis certificate is executed by LIBERTY MUTUAL GROUP as respects s~ch insurance as is afforded by Those Companies
Wayne, PA
~ ----- OFFICE
(610)-971-9394
02/20/98
PHONE NUMBER
DATE ISSUED
BS 772L R2