Certificate of Insurance
Certificate oflnsurance
This certificate is issued as a matter of information only and confers no rights upon you the certificate holder,
extend, or alter the covera e afforded b the olicies listed below,
This is to certify that (Name and address oflnsured)
This certificate is not an insurance policy and does not amend,
~.:~ Libertx
\p MUtualTM
General Asphalt Co.
4850 N,W, 72 Ave
Miami, FL 33166
is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below, The insurance afforded by the listed policy(ies) is subject to all their
terms, exclusions and conditions and is not altered by any requirement, term or condition of any contract or other document with respect to which this certificate may be
issued,
Ex
1/1/03
Extended
X Policy Term
Workers Compensation
111103
TB2-151-410483-192
General Liability
Claims Made
X Occurrence
Retro Date
AP
BY
DATE
WAIVER
111/03
AS2-l5l-410483-332
Automobile Liability
X Owned
X Non-Owned
X Hired
Umbrella Excess Liability
111103
llI1-151-410483-172
Limits ofLiabili
Coverage afforded under WC law of Employers Liability
the following states:
FL
Bodily Injury By Accident
$500,000 Each Accident
Bodily Injury By Disease
$500,000 Policy Limit
Bodily Injury By Disease
$500,000 Each Person
General Aggregate-Other than Prod/Completed Operations
$2,000,000
Products/Completed Operations Aggregate
$1 000000
Bodily Injury and Property Damage Liability
$1 000000
Personal and Advertising Injury
$1 000000
Other Liability Other Liability
$100,000 Dm to rem mtd to $5,000 Medical Pa ents
Each Accident - Single Limit - B. I. and P. D. Combined
$1,000,000
Each Person
Per
Occurrence
Per Person /
Or anization
Each Accident or Occurrence
Each Accident or Occurrence
$2,000,000 Single Limit for Bodily Injury and Property Damage Liability
over Underlying Limit
C --Re: Stock Island Roads
o
M Monroe County Board of County Commissioners, its employees and officials will be included as additional insured on all policies with the exception of workers
M compensation,
E
N
T
S
*Ifthe 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 files 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 have any 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 right hand comer of this certificate, The 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 below), Before the 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 to:
r Monroe County Board of County Commissioners I
Certificate Attn: Engineering Dept
Holder 1100 Simonton Street
Key West, FL 33040
~~-~--.:r~ .
L/
James R. Fiet
Authorized Re resentative
L J Office / Phone FT, LAUDERDALE, FL / 800-542-0055
Date Issued: 6/21/02 Prepared By: VS
This certiticate is executed by Liberty Mutual Insurance Group as respects such insurance as is afforded by those companies, BMOO68