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Docusign Envelope ID: AB158799-C7BC-4838-B581-OC84CDE5OB97 <br />C <br />ACORD CERTIFICATE OF LIABILITY INSURANCE I <br />DATE(MM/DD[YY) <br />PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION <br />ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE <br />HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR <br />ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. <br />INSURERS AFFORDING COVERAGE <br />YOUR COMPANY NAME HERE I 1INSURERC, Companies providing coverage <br />INSURER D. <br />COVFRAGFS <br />THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING <br />ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR <br />MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH <br />POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br />INSR <br />TYPE OF INSURANCE <br />POLICY NUMBER <br />POLICY EFFECTIVE <br />DATE (mminniyy) <br />POLICY EXPIRATIONLTR <br />LIMITS <br />GENERAL LIABILITY <br />COMMERCIAL GENERAL LIABILITY <br />,,.,:. =CLAIMS MADE OCCUR <br />EACH OCCURRENCE <br />$ <br />Must Include General Liability <br />FIRE DAMAGE (Any one fire) <br />$ <br />MED EXP (Any one person) <br />$ <br />PERSONAL & ADV INJURY <br />$ <br />GENERAL AGGREGATE <br />$ <br />GENT AGGREGATE LIMIT APPLIES PER: <br />policy = project ❑ loc <br />PRODUCTS - COMP/OP AGG <br />$ <br />AUTOMOBILE <br />LIABILITY <br />ANY AUTO <br />ALL OWNED AUTOS <br />SCHEDULED AUTOS <br />HIRED AUTOS <br />NON -OWNED AUTOS <br />SAMPLE CERTIFICATE <br />GARAGE LIABILITY <br />ANY AUTO <br />AUTO ONLY -EA ACCIDENT <br />$ <br />OTHER THAN EA ACC <br />AUTO ONLY: AGG <br />$ <br />$ <br />EXCESS LIABILITY <br />OCCUR CLAIMS MADE <br />DEDUCTIBLE <br />RETENTION $ <br />EACH OCCURRENCE <br />$ <br />AGGREGATE <br />$ <br />$ <br />$ <br />COMPENSATION AND <br />EMPLOYERS' LIABILITY <br />WC STAT01 H- <br />U-ORY LIMITS I I ER <br />TWORKERS <br />E.L. EACH ACCIDENT <br />$ <br />E.L. DISEASE - EA EMPLOYEE <br />$ <br />E.L. DISEASE - POLICY LIMIT <br />OTHER <br />Certificate must contain wording similar to what appears below <br />DESCRIPTION OF OPERAT ONS LOCAT ONSIVEH CLES EXC <br />"THE CERTIFICATE HOLDER IS NAMED AS ADDITIONALLY_INSURED WITH REGARD TO GENERAL LIABILITY" , <br />C:tK l II-IUA I t HULUtK ADDITIONAL INSURED; INSURER LETTER: C:ANC:tLLA I IUN <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION <br />City of Pembrok lines IL 30 DAYS WRITTEN <br />601 City Center way City Must Be Named as Certificate Holder LEFT. <br />Pembroke Pines FL 33025 <br />AUTHORIZED REPRESENTATIVE <br />RD <br />(DACORD CORPORATION 1988 <br />n <br />