COI Expires 09/14/2018/ 1 ®
A� o CERTIFICATE OF LIABILITY INSURANCE
DATE (MWDD/YYYY)
9/15/2017
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 have ADDITIONAL INSURED provisions or 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)CONTACT
PRODUCER
The James B. Oswald Company
1100 Superior Avenue, Suite 1500
Cleveland OH 44114
NAME: Serena Turchik
P"FAX
(AI°NE 216-777-6134 A/C No
E-MAIL . STurchik@oswaldcompanies.com
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: Hartford Casualty Ins. Co. '29424
INSURED MBIK2-1
K2M Design, Inc.
INSURERB:XL Specialty Insurance Co.
37885
INSURER C: Hartford Accident & Indemnity
22357
INSURER D :
1150 Virginia St
KEY WEST FL 33040
INSURER E :
INSURER F :
^n MM Clf`ATC M"RAnco. 667300997 RFVISIAN NLIMRER:
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
LTR
TYPE OF INSURANCE
ADIX
INSD
WVD
POLICY NUMBER
POLICY EFF
MMIDD/YYYY
POLICY EXP
MMIDD/YYYY
LIMITS
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$
CLAIMS -MADE OCCUR
MED EXP (Anyone person)
$
PERSONAL & ADV INJURY
$ _
GENERAL AGGREGATE
$
EGE�11AGGREGATELIMITAPPLIESPER:
PRODUCTS -COMP/OP AGG
0
$
PRO-
POLICY , LOC
JECT
$
OTHER:
C
AUTOMOBILE LIABILITY
Y
Y
45UECBH0542
9/14/2017 1
9/14/2018
COMBINED SINGLE LIMIT
Ea accident)
$1,000,000
BODILY INJURY (Per person)
$
I
X ANY AUTO
�OWNED SCHEDULED
IAUTOS
BODILY INJURY (Per accident)
$
AUTOS ONLY
HIRED NON -OWNED
1
PROPERTY DAMAGE
j $
X AUTOS ONLY X AUTOS ONLY
Per accident
I$
X AI Primary
A X UMBRELLA LIAB
X , OCCUR
Y
Y
145SBA107008
9/14/2017
9/14/2018
EACH OCCURRENCE
$1,000,000
AGGREGATE
$1,000,000
EXCESS LIAB
1 CLAIMS -MADE
DED X RETENTION $10,000
Excludes Professional
i
$
A
WORKERS COMPENSATION
y
45SBA107008
9/14/2017
9/14/2018
PER
STATUTE X OERH
OH -STOP GAP
E.L. EACH ACCIDENT
$1,000,000
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
N/A
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYE
$1,000,000
E.L. DISEASE -POLICY LIMIT
$1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
B Professional Liability
N
Y
DPR9914922
6/12/2017
Each Claim $1,000,000
Claims Made
Retro Date: 911/2001
16/12/2018
Aggregate $1,000,000
Pollution & Envir. Liab. Included
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Additional Insured and Waiver of Subrogation as designated above is provided when required ot the Namead Insured by written contract or
agreement.
EMENT
4BY
*/AY
CERTIFICA 1 E NULUtK
Monroe County
1100 Simonton Street
Room 2-219
Key West FL 33040
A
G+'
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
lJ 7`Jaa-LUIa A%,um Li 6.VRrVRA r rVrV. m rrynw -wa -cv.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
Bureau of Workers'
Ohio Compensation
30 W. Spring St.
Columbus, OH 43215
Certificate of Ohio Workers' Compensation
This certifies that the employer listed below participates in the Ohio State Insurance Fund as required
by law. Therefore, the employer is entitled to the rights and benefits of the fund for the period
specified. This certificate is only valid if premiums and assessments, including installments, are paid by
the applicable due date. To verify coverage, visit www.bwc.ohio.gov, or call 1-800-644-6292.
This certificate must be conspicuously posted.
Policy number and employer
01493325
K2M DESIGN INC
9435 WATERSTONE BLVD. SUITE 250
CINCINNATI, OH 45249
www.bwc.ohio.gov
Issued by: WC
'erg /.y..
Period Specified Below
07/01/2017 to 07/01/2018
Administrator/CEO
You can reproduce this certificate as needed.
Ohio Bureau of Workers' Compensation
Required Posting
Effective Oct. 13, 2004, Section 4123.54 of the Ohio Revised Code
requires notice of rebuttable presumption. Rebuttable
presumption means an employee may dispute or prove untrue
the presumption (or belieo that alcohol or a controlled substance
not prescribed by the employee's physician is the proximate
cause (main reason) of the work -related injury.
The burden of proof is on the employee to prove the presence of
alcohol or a controlled substance was not the proximate cause of
the work -related injury. An employee who tests positive or
refuses to submit to chemical testing may be disqualified for
compensation and benefits under the Workers' Compensation
Act.
Bureau'of Workers'
Ohio Compensation You must post this language with the Certificate of Ohio Workers' Compensation.
LJI--Z9 BWC-1629 (Rev. July 1, 2015)