Certificate of Insurance
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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 I'.ND ODES NOT I'.MEND, EXTEND, OR I'.LTER THE COVERI'.GE I'.FFORDED BY THE POLICIES LISTED
BELOW.
This is to Certifv that
Staff Leasing, L.P" Total Employee Leasing Services,L.P.,
Florida Payroll Leasing & Services, L.P. ,Slaff Leasing, II, L.P..
Staff Leasing III, L.P., and It's Affiliates and Subsidiaries
130\ 6th Ave. West, Suite \01
Bradenton PL 34206
Name and
address of
Insured
LIBER1Yt.
MUTUALW
is at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the
li~ted 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 resnect to which this certificate may be issued,
ERnFlCATE EXP. DATE
TYPE OF POLICY ,0 CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
o EXTENDED
[&] POLICY TERM
Coverage Afforded Under we EMPLOYERS LIABILITY
Law of the Following States:
FL,GA,AL,AZ,CO, Bodily Injury By Accident Each
WORKERS CT, ID, IL, IN, KY, 1,000,000. Acddent
COMPENSATION 3-1-96 WC1-651-004110-015 LA,MD,MI,MO,MS, Bodily Injury By Disease Policy
NC,NH,NY,OR,PA, 1,000,000. Limit
SC,TN,TX,VA Bodily Injury By Disease Each
1,000,000. Person
GENERAL LIABILITY Generall'.ggregate-Other than Prod/Completed OperaUons
o CLAIMS MI'.DE A~YR SK M^"\GE# Products/Completed Operations Aggregate
- '
BY ~. -/./7 /. ()-t:./c.
I RETRO DATE I DATE f7 c.~.t::.. Bodily Injury and Property Damage Liabilily Per
I '7'-,;l. 7" -f'...s Occurrence
Personal and Advertising Injury Per Person!
o OCCURRENCE WAIVER: N/A As Organization
Other: -I Other:
AUTOMOBILE Each Accident ~ Single limit -
LIABILITY B. I. and P. D. Combined
DOWNED Each Person
0 NON-OWNED Each Accident or Occurrence
0 HIRED Rec~ccident or Occurrence
Rid, U__. 0, T n.. -
OTHER '11/5. /9 S/"
DATE { (
INITIAL ,-'
ADDITIONAL COMMENTS Employees leased to : Their Effective Date:
2832 : 07/03/')4
AMERICAN ENERGY & SHEET METAL CORP
The above referenced Worker's Compensation policy provides statutory benefits only to employees of the Named Insured{s) on the policy, not
to employees of any other employer.
'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: I'.NY PERSON WHO. WITH INTENT TO DEFRAUD OR KNOWING THAT HE 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.
NOTICE OF CI'.NCELLI'.TION: (NOT APPLlCI'.BLE UNLESS A NUMBER OF OMS IS Liberty Mutual
ENTERED BELOW.) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT Insurance Group
CANCEL OR RE:DUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES
UNTIL A. T LEAST ~ DA. YS NOTICE OF SUCH CANCEL\..ATION HAS BEEN MAILED TO:
MONROE COUNTY/BOARD OF COUNTY
CERTIFICATE 5100 COLLEGE RD
HOLDER KEY WEST, FL 33040
JOHN SHAHINIAN
AUTHORIZED REPRESENTATIVE
04/03/95
Orlando, Fl
OFFICE
DATE ISSUED
This cer\\1\ca\e is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such insurance as is afforded by Those Companies
Cc '. CltUOY S/TwYE"'C..
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