Certificate of Insurance
This certificate is executed b Libertv Mutual Insurance Grou as res ects such insurance as is afforded b those com anies. BM0068
Certificate of In.urance
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 b the olicies listed below.
This i. to certify that (Name and addre<< of Insured)
~.....': Liberty
~ Mutual
GENERAL ASPHALT CO., INC,
4850 NW 72 AVENUE
MIAMI, FLORIDA 33166
is, at the issue date of this certIficate, insured hy the Company under the policy(ies) listed below, The msurance afforded by the listed policy(.es) IS subject to all their terms, exclusions and conditions
and is not altered b an re uirement teon or condition of an contract or other document with res ect to which this certificate ma be issued.
01/01/2004
x
Extended
Policy Term
Workers Compensation
01101/2004
TB2-151-410483-193
General Liability
Claims Made
Occurrence
Retro Date
01101/2004
ASI-151-410483-333
Automobile Liability
X Owned
X Non-Owned
X Hired
Umbrella Excess Liability
01/0112004
THI-151-410483-173
Limits of Liabili
Coverage afforded under WC law of Employers Liability
the following states:
Bodily Injury By Accident
$500,000 Each Accident
Bodily Injury By Disease
$500,000 Policy Limit
Bodily Injury By Disease
$500,000 Each Person
FL
General Aggregate-Other than Prod/Completed Operations
$2,000,000
Products/Completed Operations Aggregate
$1 000000
Bodily Injury and Property Damage Liability
$1000000
Personal and Advertising Injury
$1,000,000
Other Liability
$ I 00,000 Dmg to prem rmd to y
Each Accident - Single Limit - B.
$1,000,000
Each Person
Per
Occurrence
Per Person /
Organization
Other Liability
$5,000 Medical Payments
I. and p, D. Combined
Each Accident or Occurrence
Each Accident or Occurrence
$2,000,000 Single Limit for Bodily Injury and Property Damage Liability
over Underlying Limit
C
o
M
M THE CERTIFICATE HOLDER IS ADDITIONAL INSURED AS TO GENERAL AND AUTO LIABILITY.
E PROJECT NAME: KEY LARGO ROADS XVII.
N
T
S
'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 / she is facilitating a fraud against an insurer, submits an application or tiles a claim containing a false or
deceptive statement is guilty of insurance fraud,
Important information to Florida policyholders and certificate holders: in the event you tAn questions or need information about this certificate for any reason, please contact your local sales
producer, whose name and telephone number appears in the lower left comer ofthi~,&;'tifiC:;;, he appropriate local sales office mailing address may also be obtained by calling this number,
Notice of cancellation: (not applicable unless a number of days is entered bel~wr Befof~~e 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 mailed _~, *'
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.OM;:'lISSIONERS
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Certificate Holder:
_Tun"lcs R.. Fiet
^Llthor"izcd R-:,~~_c:~.C:~"ltat~vc
Date Issued: 01/01/03 Prepared By: CS