Hybrid Concrete Structures - Laserfiche WebLink

Home Browse Search

() 9 (~) () , () ~ () , <) () ~ () ~ () () ~ () () 't1 (1 '; () '; '''\ "'If C) <J <) () rI () rI () ~ () wi C) (' rI () wi ("\ rI 9 c~ 'r! CJ (J Q c~ wi ("' " CJ , (' I rI , (' I wi I . Ie:) IQ Ie.) C; 10 ,9 ^ I , ~ ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY) .,.. 15SZKGKF 01/22/2008 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Risk Transfer Holdings ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 301 E Pine Street, Suite 350 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR orlando, FL 32801 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Work First Casualty Sourceone Administrative Services 1588 Atkinson Road INSURER B: suite 201 INSURER C: Lawrencevi1le, GA 30043 INSURER 0: INSURER E: COVERAGES THE POLlelES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR Nsili TYPE OF INSURANCE POLICY NUMBER P8kf~~g,,"l8l)y'1 Pg~,w,~,h'b",W\N LIMITS ~ERAL L1ABIUTY EACH OCCURRENCE $ OMMERCIAL GENERAL LIABILITY liRM'Es rEa occurencel S I-- CLAIMS MADE 0 OCCUR I-- MED EXP (Any one person) $ PERSONAL & ArN INJURY $ GENERAL AGGREGATE $ ~1. AGG~En LIMIT APn PER: PRODUCTS. COMPIOP AGG $ POLICY ~ LOC ~OMOBILE LIABILITY COMBINED SINGLE LIMIT $ Am AUTO (Ea accident) I-- "- ALL OWNED AUTOS BODILY INJURY $ "- SCHEDULED AUTOS (Per person) - HIRED AUTOS BODILY INJURY NON.QWNED AUTOS I (Per acc:fdanl) $ - PROPERTY DAMAGE $ (Per acddant) RRAGE LIABILITY AUTO ONLY. EA ACCIDENT $ Am AUTO OTHER THAN EAACC $ AUTO ONLY: AGG S OESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR 0 CLAIMS MADE AGGREGATE $ . ... $ ~ DEDUCTIBLE $ RETENTION $ $ A WORKERS COMPENSATION AND WC-2007-00023-08 01/01/2008 01/01/2009 X I T~g,~T~ru-., I IWJl- EMPLOYERS' LIABILITY ANY PROPRIETORlPARTNERlEXECUTlVE E.L EACH ACCIDENT $ 1,000,000 OFFlCERlMEMBER EXClUDED? E.L. DISEASE - EA EMPLOYEE S 1,000,000 ~rEM.'t"~~~%1~s below E.L DISEASE - POLICY LIMIT $ 1,000,000 OTHER DESCRIPTION OF OPERATIONS (LOCATIONS IVEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS *10 days notice of cancellation for nonpayment of premium. Attached is the requested Certificate of Insurance on behalf of Hybrid Concrete Structures,LLC that covers employees of the insured as respects to the workers compensation ag7eement with SourceOne Administrative Services, Inc. and Hybrid Concrete Structures, LLC, as of 5/4/07. Wa~ver of Subrogation in favor of the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURETD DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANYKlND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. Hybrid Concrete Structures,LLC AUTHORIZED REPRESENTATIVE ~ 685 Red Oak Road Stockbridge, GA 30281 ACORD 25 2001 Page 1 of L 108) @ ACORD CORPORATION 1988