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<br />TAB M - FORMS ANDATTACHMENTS
<br />DATE (MM/DD/YYYY)CERTIFICATE OF LIABILITY INSURANCE
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />CONTACTPRODUCERNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):E-MAILADDRESS:
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />ADDL SUBRINSR POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITSPOLICY NUMBERLTR (MM/DD/YYYY)(MM/DD/YYYY)INSD WVD
<br />COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
<br />DAMAGE TO RENTEDCLAIMS-MADE OCCUR $PREMISES (Ea occurrence)
<br />MED EXP (Any one person)$
<br />PERSONAL & ADV INJURY $
<br />GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE $
<br />PRO-POLICY LOC PRODUCTS - COMP/OP AGG $JECT
<br />$OTHER:
<br />COMBINED SINGLE LIMITAUTOMOBILE LIABILITY $(Ea accident)
<br />BODILY INJURY (Per person)$ANY AUTO
<br />ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOSNON-OWNED PROPERTY DAMAGE $HIRED AUTOS (Per accident)AUTOS
<br />$
<br />UMBRELLA LIAB EACH OCCURRENCE $OCCUR
<br />EXCESS LIAB CLAIMS-MADE AGGREGATE $
<br />$DED RETENTION $
<br />PER OTH-WORKERS COMPENSATION STATUTE ERAND EMPLOYERS' LIABILITY Y / NANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $N / AOFFICER/MEMBER EXCLUDED?(Mandatory in NH)E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />CERTIFICATE HOLDER CANCELLATION
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />© 1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01)
<br />PIRTCON-02 CRYSTAL
<br />12/23/2014
<br />Acrisure, LLC d/b/a InSource9500 South Dadeland Boulevard4th FloorMiami, FL 33156-2867
<br />(305) 670-6111 (305) 670-9699
<br />National Fire Ins.Co.20478
<br />James B. Pirtle Construction Company Inc.
<br />dba Pirtle Construction Company
<br />5700 Griffin Road, Suite 200
<br />Davie, FL 33314
<br />North River Insurance Co 21105
<br />Valley Forge Insurance Co.20508
<br />Columbia Casualty Company 31127
<br />A X 1,000,000
<br />X 5091001123 01/01/2015 01/01/2016 300,000
<br />5,000
<br />1,000,000
<br />2,000,000
<br />X 2,000,000
<br />1,000,000
<br />A X 5091001106 01/01/2015 01/01/2016
<br />X X
<br />XX 15,000,000
<br />B 5811037425 01/01/2015 01/01/2016 15,000,000
<br />X
<br />C 5091001137 01/01/2015 01/01/2016 1,000,000
<br />1,000,000
<br />1,000,000
<br />D Professional Liab CPB288345903 02/27/2014 02/27/2015 Limit Each Claim 2,000,000
<br />D $10,000 SIR CPB288345903 02/27/2014 02/27/2015 Aggregate 5,000,000
<br />SPECIMEN CERTIFICATE FOR INFORMATIONAL
<br />PURPOSES ONLY. IF ACTUAL CERTIFICATE NEEDED
<br />IT WILL BE ISSUED TO A SPECIFIC ENTITY AND
<br />ADDRESS.
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