COI Expires 06/18/2017 a Ac � DATE (MMfDD7YYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/17/2016
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Geri Navarro
NAME:
AISI dba Pan American Insurance Agency, Inc. NQ.EXt)• (925) 407-0417 FAX
A/c,No):
CA License 11 0'89850 E-MAIL
ADDRESS: gnavarro@ascensionins.com
1277 Treat Blvd., Suite 400 INSURER(S) AFFORDING COVERAGE NAIC
Walnut Creek CA 94597 INSURER A :Travelers Prom. Cas. Co. of America 25674 _
INSURED INSURER B :Travelers Ind. Co . of Connecticut 25682
Ascension Insurance Holdings, LLC INSURER C :
Ascension Benefits & Insurance Solutions INSURERD:
700 SE Central Parkway INSURERE:
—
Stuart FL 34994 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL166961192 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POUCY EFF POLICY EXP LIMITS
LTR INSD WVD POUCY NUMBER IMDD/YYYY) (MWDDIYYYYI
A X COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE $ 1,000,000
DAMAGE TO
CLAIMS -MADE X OCCUR PREMISES (Ea RENTED $ 1,000,000
X 6308F426365TIL16 6/18/2016 6/18/2017 MED EXP(Anyoneperson) $ 5,000
PERSONAL 8 ADV INJURY $ 1,000,000
GEM_ AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY I JEI LOC PRODUCTS - COMP /OP AGG $ 2,000,000
OTHER: $
B AUTOMOBILE UABIUTY COMBINED LIMIT $ 1,000,000
(Ea mciden
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BA8F42609ATIL16 6/18/2016 6/18/2017 BODILY INJURY (Per accident) $
AUTOS NONCWMED PROPERTY DAMAGE
X HIRED AUTOS R AUTOS (Per accident) $
Non - owned $
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS UAB — CLAIMS.MADE AGGREGATE $
DED 1 RETENTION $ $
A WORKERS COMPENSATION X I STATUTE ER
AND EMPLOYERS' LIABIUTY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N N! A E.L. EACH ACCIDENT $ 1,000,000
(Mandatory H) EXCLUDED? Y. B8F401309TIL16 6/18/2016 6/18/2017
(Mandatory to NH) E.L DISEASE - EA EMPLOYEES i3O00,000
S s, des u nder
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached W more space Is required)
Monroe County BOCC is additional insured as required by contract.
APPR� ED : EMENT
:Y �►_
D• Iilt.Y[
INAI ,. S
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Monroe County BOCC THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
1100 Simonton Street ACCORDANCE WITH THE POLICY PROVISIONS.
Suite 2 -268
Key West, FL 33040 AUTHORIZED REPRESENTATIVE
Steve Martin /GERI
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ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (201401)