Certificate of Insurance Ac D) CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDNYYY)
10/4/2022
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 Ifeu of such endorsement(s).
PRODUCER CON T
RBN Insurance Services NAME: one White
PHONE
303 E Wacker Dr Ste 650 .312-856-9400 FAX No;312-856-9425
Chicago IL 60601 noDRrss; swtiite@rbninsuranre.com
INSURERS AFFORDING COVERAGE NAIC0
lNsuRERA:Hartford Fire Insurance Co. 19682
INSURED SAFELLC-01 INSURERB.Hartford Casualty Insurance Co 29424
M.T. Causley, LLC
Carr
10720 Caribbean Blvd, Suite 650 INSURERc:Great American E&S Ins,Co. 37532
Cutler Bay FL 33189 INSURERD;Bridgeway Insurance Company 12489
imsuRERE;Twin City Fire Insurance Co. 29459
[NSURERF: Lexington Insurance Company 19437
COVERAGES CERTIFICATE NUMBER:1604145487 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.
IL7R TYPEOF[NSURANCE AD R POLICYEFP POLICY FXP
IMMtD01YYYYIMMIDD LIMITS
A X COMMERCIAL GENERAL LABILITY Y 83UENZV3951 IOW022 1OW023 EACH OCCURRENCE $1,000,600
CLAWS-MADE IJ OCCUR PREMISES Ea occurrence $1,000,000
MED EXP(Arty one person) $10,000
PERSONAL&ADV INJURY $1,000.000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
X POLICY 0 jECT LOG PRODUCTS-COMPIOPAGG s2,000000
OTHER: s
5 AUTOMOBILE LIABILITY Y 83UENPY9100 10/3/2022 10/312023 COMBINED SINGLE LIMIT 51,00D,000
Ea accdent
X ANYAUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY PeracddeM) $
AUTOS ONLY AUTOS
X HIRED x NON-OWNED PROPERTYOAMAGE
AUTOS ONLY AUTOS ONLY Per accident)9
E.Ccess At.U.b.- $1,000,000
D UMBRELLA UAB X OCCUR SE-A7-XL-000207MI 10/3/2022 1013/2023 EACHOCCURRENCE $5,000,000
X FJ(CESSLWB CLAIMS-MADE AGGREGATE $5,000,000
DED I X I RETENTION$ $
E WORKERS COMPENSATION 83WECE0623 5112/2022 5/12/2023 X I PE
STARTUTE ER
AND EMPLOYERS'LIABILITY Y I N
ANYPROPRIETORIPARTNERIEXECUTIVE NIA
E.L.EACH ACCIDENT $1.000.000
OFFICERIMEM13ER EXCLUDED?
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below ELL DISEASE-POLICY LIMIT $1,000,000
C Professional UabiTity TER 2881558 10IW2022 10/3/2023 Eec>ti ClairNAggregate 10.000,000
F Excess Uab(2nd)Layer 011170891 1013/2022 1013/2023 Each OcdAggregate 5,000.000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addlgonal Remaft Schedule,may be attached If more space Is required)
'Excess Auto Liability Buffer Policy:
Endurance American Specialty
EXT30025875000
1013/2022-2023
Monroe County SOCC are Additional Insured as respects the General Liability and Auto Liability as required by written contract
Workers Compensation Coverage Includes:FL A1ru ,T
CERTIFICATE HOLDER CANCELLATIC
DAI
;mm - .
THEUEEXPIRRAA7 WN _ ORN
Monroe County BOCC ACCORDANCE
Insurance Compliance
PO Box 100085-FX AUTHOR2ED REPRESENTATIVE
Duluth GA 30096
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