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• • • 1 • CERTIFICATE OF INSURANCE • This certifies that ❑ STATE FARM FIRE AND CASUALTY COMPANY.Bloomington.Illinois • 0 STATE FARM GENERAL INSURANCE COMPANY,Bloomington,Illinois t 0 STATE FARM FIRE AND CASUALTY COMPANY,Aurora.Ontario • ® STATE FARM FLORIDA INSURANCE COMPANY,Winter Haven.Florida ❑ STATE FARM LLOYDS.Dallas.Texas • I insures the following policyholder for the coverages indicated below: • Policyholder FRANK COSTOYA ARCHITECT, P.A. 5230 S UNIVERSITY DR. STE 103 DAVIE, FL 33328 • Address of policyholder , Location of operations SAME • Description of operations ARCHITECT • The policies listed below have been issued to the policyholder for the policy periods shown. The insurance described in these policies is subject • to all the terms,exclusions,and conditions of those policies.The limits of liability shown may have been reduced by any paid claims. POUCY PERIOD LIMITS OF LIABILITY • POUCY NUMBER TYPE OF INSURANCE Effective Date : Expiration Date (at beginning of policy period) Comprehensive BODILY INJURY AND • Business Liability PROPERTY DAMAGE • This insurance includes: ❑Products-Completed Operations 0 Contractual Liability Each Occurrence $ • ❑Personal Injury • 0 Advertising Injury General Aggregate $ • ❑ Products-Completed $ ❑ Operations Aggregate • POLICY PERIOD BODILY INJURY AND PROPERTY DAMAGE EXCESS LIABILITY Effective Date Expiration Date (Combined Single Limit) • 0 Umbrella Each Occurrence $ • ❑Other Aggregate $ POLICY PERIOD Pan I-Workers Compensation - Statutory • Effective Data : Expiration Data 98-BH-E065-i F Workers'Compensation 08/13/11 08/13/12 PanlI-Employers Liability • and Employers Liability Each Accident $ 500,000 • Disease-Each Employee $ 500,000 Disease-Policy Limit $500,000 • POLICY PERIOD LIMITS OF LIABILITYPOLICY NUMBER TYPE OF INSURANCE Effective Date ; Expiration Data (at beginning of policy period) • • • THE CERTIFICATE OF INSURANCE IS NOT A CONTRACT OF INSURANCE AND NEITHER AFFIRMATIVELY NOR NEGATIVELY • AMENDS, EXTENDS OR ALTERS THE COVERAGE APPROVED BY ANY POUCY DESCRIBED HEREIN. Name and Address of Certificate Holder If any of the described policies are canceled before • their expiration date,State Farm will try to mail a City of Sun-.y Isles Beach written notice to the certificate folder 30 days before • 18070 Coil ins Avenue cancellation.If however,we fail to mail such notice. Sunny isles Beach, FL 33160 no obligation or liability will be imposed on State Fane • or it$'agents or representatives. i% • -6,-,,,,, --(-4}2,4 ,,,-,....- s ignature of Authorized Representative ® AGENT . /24/12 Title Date • JANET FZRNANDDEZ • Agent Name Telephone Number 554-680-66605 • Agent's Code Stamp Agent Code 2719 • AFO Code F603 • sSa-69a a 6 Prinks in U.5 A Rev.05Oa-200e • • • 5