Certificates of Insurance '4C� CERTIFICATE OF LIABILITY INSURANCE DATE(MMrpD/YYYY)
"1 7 z'�
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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
Ws certificate does not confer rights to the certificate holder In lieu of such endorsements.
PRODUCER CNAOIN A T Brenda Young-Epps
Marsh USA,Inc
Two Alliance Center PHONE (404)995 3074 Fk No
3560 Lenox ROW.Suite 2400 E-MAIL breMa.youngepps@marsh.com
Atlanta,GA 30326
Attn:Atlanta.CedReques9@marsh.wm I Fax:212 948-4321 INSUREFttSJ AFFORDING COVERAGE NAIL p
CN142326389-CAS-GAUWX-22-23 INSURER A:Evanston Insurance Company 35378
INSURED INSURER B:Indemnity Ins Co Of North America 43575
PlayCore Wisomsin,Inc.
Dba GameTlrne INSURER C:ACE Property And Casually Ins Co 20699
15D PlayCore Drive SE INSURER D:ACE American Insurance Company 22667
Fort Payne,AL 35967
INSURER E:National union Fire Ins Co.of Pittsburgh PA 119445
INSURER F:ACE Fire Underwriters Insurance Compan v 120702
COVERAGES CERTIFICATE NUMBER: ATL-005433040-06 REVISION NUMBER: 4
THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN„ THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR i AR Wvc POLICY NUMBER Y ^LTR TYPE OF INSURANCE .. . ,,,_.
A y, COMMERCIAL GENERAL LIABILITY ° 2 ,,,m..... 22 08M 2DPY"r'Y9M l LIMITS
..
�X M4�L�"�PSC001627 OEJ01IZ0 EFF PO .... .. - .
CLAIMS-MADE x.....l OCCUR a 112(123 ,$FACHOCCURRENCE 2,1DO,000',
X MED EXP�yonew vper� I S -. . ..
SIR f250„000 Per Ccc. 10 000„
„m P1ERS0NALBA.DVINJURY $ 2OD0.000
N POLICY AGGREGATE ECT LOC PRODUCTS•COMPIOP A
SPER. GENERAL AGGREGATE •S 4000000
PRO
.. LIMIT APPLIES ,. .,- 1-1-GG�$I'll 000000
OTHER: POLICY AGGREGATE S 10,D00,DD0
O01023B AUTOMOBILE LIABILITY OS}1 yBIN7nsl W„ s 1.000,000 X ANY AUTO BODILY INJURY(Per person) $
p "BODILY ..�......... .
OWNED SCHEDULED � . .
. AUTOS ONLY �, AUTOS
INJURY(Per accident) $...
HIRED NON NED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY ? r,4r,+j;a,n $
i Camp.lColl.Ded.:$1,000 $
X UMBRELLA LIAR X OCCUR xEUG79549549 404 08N112022 08/01/2023 EACH OCCURRENCE S 10,000,0t
"'"JEXCESS LIAR CLAIMS-MADE (RETENTION Umb lrophe L25,0D0 - AGGREGATE $ 10,000,001)
DIED X IRETENTIONSO • $
KERS COMPENSATION
WO
D OORCER Rlr:T PJPAR UDUF- YIN NIA. WL 2 202 ON112023 X H
® SCF C50669786 08101120F�fTJA�. £1,.,.,,,,, ,
AND EMPLOYERS'LIABILITY � 22 08101/2023 E LEACH ACCIDENT S 1�•�
F DESCRIPTION OF OPERATIONS below (seeAdditional Page} C O8RI1f2022 061U1�2023 E.L.DISEASE..POLICY LIMIT S 1 ., .
A FFICE}PRIETORIPARBNERIEXECUTIV E
(Mandatory } E.L.DISEASE FA EMPLOYEE $ D00,000
IP es,describe under
;� .,
E Excess Umbrella 021W8174 ON112022 ON112023 Each Occurrence 15,000,000
Aggregate 15,000,D00
DESCRIPTION OF OPERATIONS B LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may Ee attached If more space Is required)
RE: All Jobs
Monroe County SOCC and Monroe County Shedfrs Office are listed as additional insured as their interests may appear,during and until completion of the
referenced project,on a primary a nd non-contributory basis via attached CG 2010.when required by written contract. A Waiver of Subrogation applies in favor
of the additional insured on the Workers Compensation policy,when required by written contract.
AP
R18K a
eY
CERTIFICATE HOLDER CANCELLATION
Monroe Cou my BOCC SHOULD ANY OF THE ABOVE DESCR i*ft M EO BEFORE
1100 Simonton Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Key West,FL W40 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
-
01988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: CN102326389
LoC#: Atlanta
ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY NAMEDINSURED
Marsh USA,Inc. AlayCare Wis=sin,Inc.
Oba GameThe
POLICY NUMBER 150 PlayCoe Drive SE
Fat Payne,AL 35967
CARRIER NAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Workers'Compensation(Continued):
WLRC50669828•AL,AZ,CA,CO,FL,GA,IL,IN,KY,MI,MN,MO,NV,NY,OK,OR,PA,SC,TN,TX,UT,VA
SCF CM99786•CA,CO,FL,GA.IL,IN,MI,MN,MO,MT,NC.NM,NV,NY,OK,OR,PA,SC,TN,TX
SCF CSW69713-Wisconsin(WI)
ACORD 101 (2008101) ®2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ACC)Ra �zr-mmwDlyyyy)
CERTIFICATE 01F' LIIAB1111� ITY IINSI)RANCE 05M 112.022
................................................................................................
THIS CERTIFICATE IS ISSUED AS A IVIATT'IER OF INFOIRMAT110N 01NIX AND CONFERS NO I UPON "i't-HE CIEKTHI HOILJYEEIR. fltFs
CE1't,'n1Fl1CAT1E DOES IIWOT Alr'�IV'H?MXIIIVEILY OR INEC'PAII]VIELY AMEND, Ex'r1i'-.':N1D OR ALTER I-PIE' COVERAGE AFFORDED Ihf1P THE POUCIES
T
BII TI-111S C1ER'T'IfFl[CATi-.' OF INSUIVIkNCE DOES NOT CONST I'll'UTIE A. COIN'TRACT BlEir'WEEN 'I'll-IIIE ISSLUNG 1INSUIR11ii-T
II A1.11110RIZIErit
IREIPRESENTA111VIi"..;OR PRODUCER,ANDTIHE ClEffil'WiI HOILDII
10 f the ceillficate holder is an AIDDfTIONAL HYSURIED,the irwolllkIy(le)rinust have ADD111"110NAL,IIII UREI)provisiorns,o:ir ix,endorsedL
IV SUIBROGA'noiN IS WAI[VEID, sulbJect to the terms and condtflons of the pollicy, ceirtain policies inay require an endorseniernt, A stateirnei-A on
thils eerfificate does not cordeir H191I to the certiflicate holcier In Heu of suclih,endairserneint(s).
...................... ...................
PRODUCER '=)NIlI Brenda Young I ops
Marsh USA,kic NAME:
I..'' - -........................... ------------
"I wo Altanc4,C/anter Nistam.'--------------- (111�995 1074 Zwx
-.(AX,'..Nn,EA): ------------------------11------------------------- ---(�'X'vop:�
3560 Lenox RoacI 2.400 EMAIL
ADDIRES& brenda,youngelfiI corn
Atlanta,GA 30326 ..................--- ----------------------I-----------------.....................................
Attn:Atlanta CA�ItRequest@marsh corn Iax:212-948 4321 ...............u!yF E- -------- -------------KAM-#..........
CNM2326389 CAS-CAUft-21-22 INSURER A Evansk��I]Lj� y
................... ................................................................................................ ------------ 4rancp(�xnpan —------ 35378
....................
INStPRED INSURER B Indernirri!y1im Ca(Y Nath Arnerlu� 43575
'IlayGore Wisconsin,Inic, I I........................-- ..........--- - --------- ------------------------------
11.11a Garnet irme INSURERC ACF 0jirty-AndCasuill Ins Cc 20699
-1 1 �E�-2 ........................y........................... ----------................................
150 PlayCoie Drive K rNSURER[r)�ACE Amerlcai Insurance Cornrmx�y 22667
Ii Payne,Al 35967 11............................------------------------------------------------ ---------- ---------- ---------........................
H4SURI.'rR ir,�National Unktn FIrc Ins Co,of I'Itts t i 1�PA 194145
......................................................................................-��g ---------- ----------------------------------------------
WSUIREIR F�ACE I:�oinr UndervaiierS 1'srn11arTC(1 20 702
....................................................... mmm
COVERAGII CIER1111I rE NUMBiUR: ATL-005433040-00 REVIS110N NUMBIER� 0
............................................ ...........................................................
JjC-rrll�,[) 1 11 THIE POILEY PERIOD
Fi";�" "E 711FY THAT-11-FIIIE POILICIIIES 011l::INSURANCE , -: iAV1::: IBEEN ISSUED FoTHE INSUIRIED INA4E11l)ABOVE FOR
INDICATED, lyl0iWITHSTAII ANY 1UEOUI2EMEN-1, TERM OR CONDII rrorq OF: ANY colq'i-IRACII MR OT11 1EIRII'OCUMEN"T ffl 1H RIF.HSPEC F TO WHICH rics
CERTIFICKIE MAY BE ISSUED OR MIA)✓"PERiAlIN, -IFIE 11INSURANCIE All:11l:01FIDED BY THE POLICIES DESCRIBED HEREIN IS SLJB,JECr'iO ALL THE HERMS,
EXCLUSIONS AII C,0191:)[1 IONS OF SUCH POL Cll.".S.LIMITS SI-10VVIN MAY HAVE BEEN REDUCED BY II CLAIIII
------------------------------------------------------------------ — ------------------------------------------- -------------------------------- ----------------------------- - ------------ ............I........................................
iloUTYPE OF PINSURAINCII: ADDL SUIDR Por-licy EFF PG5G1?7" 0
1.111millf's
................. ......................................
A X COMMEIIfCIAIL,GIENERALt.11ABIII6.IIIY MKLV2PBC001 196 08911/2021 08IC 112022 EACN�OC"�C'URRENCE 2,000,000
CLAWS MAD AM
X �OCCUR IYAMAGE T-0-FRENTED----------------------------- 1100,000
APPROVED BY RISK MANAGEMENT ......-----—-----
X SIIR$250,000i'lerOcc, W:D EXIP(Any one person) $ EXCLUID1111)
.............---------- ----------
By,.. ....
REIRSONAL&ADV INJUIRY a 2,000,000
------ ........ DATE 5 1 ................I---------
G.EN'L AGGREGATE LIMITAPPUES PER: WAVER NrA YES GENERAL AGGREGATF. $
--------------------1.........................
POUCY Dy' J'E"COT- 0 LOC I-R 0 D L J C TS-COM 1:VOP Aar 4,000,000
'Y AGGREC 1010(m,000
HER� POLIC ATE
_T11—ki 1125-5................................................—--—---------------------------------- ---(',",0 P,�5'r N'E D S'o NI I—Q..E UP I'T..................
AU.I'011WOBILE LIARILI 11 Y 58030 0810112021 0610112,022 Ea acrideirc $ 1,000,00D
------ . ............................_-------
X ANY AUTO s
OWNED SCHEDULED .................. ...........................
----- Au'ros oNLY AUTCO RODRY INJURY(Per acddeno $
HVMD NONI-OWNIED -- --PR(—)PERT -[)AIqAG'E- ------------------
----- Au'ros ONLY AU1 OS 019LY -111cew—acx-dent)
Cornp,lColl.Ded,�$1,000 $
EACHOCCURRENCZ a
X UMBIRELLALIAS x ';............................................. XEUG71549501 003 081JI/2,021 10,wo'cilgo
.......... ------------------------------------
EXCESS LIAB LAWS-MADE RETEN'll ION Unib Catastrophe$25,000
T�ylcl`:"F:11 AG(GREGATI--------------- a 10,000,000
roirg$0 a
x .P.T.................... .... ......................
6IRKERS COMPENSATIOW..................................... ...............................................U67717M-Yi "OFT 76-22........... r?�
AIND EMPLOYERS'LIABILITY TlNkru i............ FEE R
YIN 8CF C67821919 .1...... -------------------------- 1,000,000 ANYPROPIRIE 11 OWPAR'r NER11EXECU WE 08/0112.021 00112.022
OFF I K'EIRWE MRMs EXCLUDE.15? NIA E-1,EACr r ACCIDE11,11 Jr
(Maindatoryin NHI) 8CF C67821877 00112021 (2101/2022 E.IL,CHSEASE-EA EMPLOYEE $ 1,000,000
--------------
1,000,01011
Uss,describe under Addifiorial Rage) E.1-DISE $
POLICY 11,
......................................................... ...................---------.................—2. . %111 .............................................
E ExcessUm1brella 5 3,43 ($0/2,021 0810112022 Each Ckuvreric"'c 15,000,OOD
Aggregate 15,000,000
................................ ....... ...... .. ................................ .............J..........................................................
DESt,Riiipir�ONOFOIPERAT'901NSIII..00A:r�O��$SIVF.-,I�IIIICL.ES (ACORD 101,Addifflonar Remarks Schedule,may tra atWciwd ifmcirs space Is requillired)
RE: All Jobs
Monroe County BOCC is listed as additional insured as their interests may appear,during and until completion of the referenced project,on a primary and
non-contributory basis via attached CG 2010,when required by written contract. A Waiver of Subrogation applies in favor of the additional insured on the
Workers Compensation policy,when required by written contract,
............................................. ................................................................11.11.1.1.1.1..............................
CERT'0CATE Ff01l-DII'-'IRL C A I C 1`21JI AT]ION
.-.-............................ ........... ................................. .................................. ................. ................
Monroe County BOCC SHOULD ANY OF THE ABOVE DESCRIBED POLACIIIES If E CANCELLED BEFORE
2798 Overseas I fighway,Srflie 400 THE EXPIRATION DXTE THEREOF, I WILL., BE, DELIVERED UN
Marattion,FLL 33050 ACCORDANCE VVITH THE P011-1I PROVIISIIONS.
.............. .................................. ................
AUTHORIZED R11EPRESENTATIVE
f IMa rsh USA Inc.
......
............................................
TION.�Ad[riql1its reserved,
............................................................................................. ............................................................
ACORID 25(2016103) 1 ACORID earn arld logo are regilsteered iniarks of ACORID
AT:w05kNC"Y CUSTOMER(V w:"N102326 8,9
D,..CC 1T: D,B�nta
.............
_.....w.w.w.
........� �1 . �������� Ill��lll! .-...........�_�__ '_IHulll ___--_ .................1-1-1-w...................-1------------ ..........
AGENCY WMA41M ED INSURED
U RE'r.',b
Mar4 USA,Inc. PlayCore Wisconsin,Inc.
__ ...............1- __,_,_,_,_,_,_,_ _____,_,_,_.. __,_,_,_,_,_,__ Doe GameTime
PCLMY NUMBER ER 150 PlayCore Drive SE
Fort Payne,AL 35967
-------------------------------------------------
TIHIS ADIIDIII TIONAL,IREMARKS NF"'ORI I IS A CT:HI DDULE TO ACO,RD FORM,
F-01RIM NUMBER, _25 IRTITL Irtlif cafe of I ialbi�iiy lrtSA �lY(!
-----.__ M
Workers'Compensation(Continued):
WLR C67821956-AL,AZ,CA,CO,FL,GA,IL,IN,KY,MI,MN,MO,NV,NY,OK,OR,PA,SC,TN,TX,UTVA
SCF C67821919-CA,CO,FL,GA,IL,IN,MI,MN,MO,MT,NC,NM,NV,NY,OK,OR,PA,SC,TN,TX
SCF C67821877..Wisoonsin(WI)
, I .M __ ................ .______ �a � ww il, ,........ ,,
COIED 1D1 2008101 @ 200 CORD C ...........
.. fRA 1I NIU rights reserved.
a
'rhe ACORID maamame acid logo am m,egiisfered inairks rap'A.COIIIRID
INSUIREd' 1"LAYCORIE GROUP, INC
POLICY EFFEC.'rUVE DATES: 08-01-2021 -08-01-.2022
POUCYNI JIMBER.- MKLV2RBC001 196 COMMERCIAL GENERAL LIABILITY
CG 2010 04 13
THIS ENDORSEMENTICHANGES THE POLICY. PLEASE READ IT CAREFULLY
ADD1710NAL INSURED OWNERS, LIEESSEES OR
MIT
CONTRA aroizs .- SQ11-,-1EDUL.1,.-1.D PEFiSON OR
ORGANIZATION
This endorsement modifies insurance provided under the foHowingl-
COMMERCiAL GENERAL UARILITYCOVERAGE PART
SCI IIEDULE
.. ................ ............. ............................-1.1.1...............—................................................--.-..............................
Narrie Of Additional Insured Plersoil
Iniz, thln� ......... ..o..........tlo.....n!92nredOrv......r..atlon( % s As required by written contract,executed by both parties All locations
prior to loss
-----........... ...........------- .............
Information required t o cmplet1this,Schedule, if no a t shown bove,will be shown in the DecWrations.
..........--....Mn
A. Sect�ion 11 -, Who Is An Insured is amended to 1. All work, including rnatedais, pwis or,
include as an additional insured the 1person(s) or equiprnent furnished in connection with such
organization(s) shown in the Schedule, but only work, on the pr9ject (othe se r than rvlce,
with respect to flablfity for, "bodily injury", "property trairiteinance or repairs) to be perfOirm(ad Iby or
darnage" or "personal aind advertising injury" on behalf of the additional Insured(s) at the
cau.,,,ed, in whole or In part,by, docafion of the covered operations has been
1. Your acts or omissions,or compieted;or
2. That podIon Of "Your' work" out of whIch the
2. The acts or ornissions of those acting ori your injury or darnage awises has been put to its
behalf; intended use by any person or organizaLion
in the penforrnance of your ongoing operations for otheir than another contractor or subcontractor
the additional insured(s) at the locafion(s) engaged in perforrrung operations for a
desiginatead above. prlirmipal as an part of the same project.
11--lowever: C. Willi rempect to the Insurance afforded lo these
1. The Insurance afforded to such additiorial additional insur,eds, the fbilowing is added to
insured only applies to ttie extent permitted by Section III-Urnits Of Insurance:
law;and If coverage provided to the additiondl insured is
2. If coverage provided to the additional IInsured is required by a contract, or agreernent, the most we
required Iby a contnact or agm ement, the MU pay oin behalf' of the additional insured is the
insurance afforded to such addlitionall insured a nount of ins urairice:
will not be broader than that whicl-i you are 1� Reqtjir(wudbytdie contra a(,,i,,or�agr'peiiieiiit,,oir
rc-.'quked by the contract or agreement to
provide for such additional insured.
B. With respect to the Insurance afforded to these
additional lrisureds, the foflowing additiondl
exciusions apply:
T'Ns insurance does not apply to "bodily Mjury" or
"propefty darnage"occurring after:
CG 20 ,10 04 13 @ Insurance Services Office, Inc.,2012 Page I of 2
If coverage proMed to the addiflonal insured is 2. Available under the applicable L.Airnits of
required by a contract,or agreement, the most we Insurance shown!in the Declarations;
will pay on behalf of the addifionW irlStged is the wt-fthever is lessa
amount of lnsurrqncea: ThiJs endorseiinent sha lil not increase the
I., Required by the contract or agreement, or appftable L.Ardts of insurance shown in the
Dedlarations,
C)finsurance SerAces Office, iVnc., 2012 Page 2 of 2
CG 20 10 04 13
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