HomeMy WebLinkAboutCertificate of Liability InsuranceA� " CERTIFICATE OF LIABILITY INSURANCE
DATE(M/2020 I()
10/27/020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT. If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement(s).
PRODUCER
Brown & Brown of Florida, Inc.
1661 Worthington Rd Ste 175
West Palm Beach FL 33409
CONTACT Maria Molina AAI
NAME:
(PA N c xt (561) 686-2266 A/c No: (561) 686-2313
E-MAIL mmolina@bb-wpb.com
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC N
INSURERA: American Casualty Company of Reading, Pennsylvania
20427
INSURED
GFA International, INC.; Obsidian Group Holdings, LLC
Obsidian Group Acquisitions, Inc.
1215 Wallace Drive
Delray Beach FL 33444
INSURER B : Transportation Insurance Company
20494
INsuRER C : National Union Fire Insurance Company of Pittsburgh PA
19445
INSURER D : Valley Forge Insurance Company
20508
INSURER E : Continental Casualty Company
20443
INSURER F :
nnvFPanrA CFRTIFICATF NUMRFR- Master 2020-2021 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES 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 CONTRACTOR 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I�TR
TYPE OF INSURANCE
INSD
WVD
POLICYNUMBER
MM/DDY EFF
MMIIDD EXP
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE X OCCUR
RENTEDDAMAGE TO
PREMISES Ea occurrence
$ 1,000,000
X
MED EXP Any onePerson),
$ 10,000
Contractual Liability
X
Cross Liability/Separation of Ins.
PERSONAL&ADV INJURY
$ 1,000,000
A
Y
6080697842
04/01/2020
.04/01/2021
GEN'LAGGREGATE LIMITAPPLIES PER:
GENERALAGGREGATE
$ 2,000,000
PRODUCTS-COMP/OPAGG
$ 2,000,000
POLICY ❑X JET LOC
$
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea accident
$ 1,000,000
BODILY INJURY (Per person)
$
X ANYAUTO
B
OWNED SCHEDULED
AUTOS ONLY AUTOS
HIRED NON -OWNED
AUTOS ONLY HAUTOS ONLY
6080697887
04/01/2020
04/01/2021
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
Per accident
$
UMBRELLALIAB
X
OCCUR
EACH OCCURRENCE
$ 5,000,000
C
EXCESS LIAR
CLAIMS -MADE
EBU049326298
04/01/2020
04/01/2021
X
AGGREGATE
$ 5,000,000
DED I X1 RETENTION $ 0
$
D
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNERIEXECUTIVE YIN
OFFICERIMEMBER EXCLUDED? �
(Mandatory in NH)
N /A
6 80697839
04/01/2020
04/01/2021
X1 BTAfUTE ERTEH
E.L. EACH ACCIDENT
$ 1,000,000
EL.DISEASE- EAEMPLOYEE
$ 1,000,000
EL DISEASE - POLICY LIMIT
1,000, 000
$
If yes, describe under
DESCRIPTION OF OPERATIONS below
Each Claim
2,000,000
E
Professional/Pollution Liability
Claims Made Policy
MCH591908633
04/01/2020
04/01/2021
Aggregate
4,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
(Lot 80) — 3337 Trinity Circle, Ft Pierce FL 34945
For Private Provider Plan Review and Inspections
rFtanFlr_eTF uni nFR CANCELLATION
SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Dr Horton Inc
ACCORDANCE WITH THE POLICY PROVISIONS.
1430 Culver Drive NE
AUTHORIZED REPRESENTATIVE
Palm Bay FL 32907
,/�jJ
/44A-1 Vogl'
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