Loading...
COI - WC Aco OR ® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY`t) 04/23/2023 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 policy(ies)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 CONTACT NAME: Marsh Affinity PHAX Marsh Affinity (A/C No,Eat): 800-743-8130 FAX C,No): a division of Marsh USA LLC. E-MAIL ADPTotalSource@marsh.com PO BOX 14404 ADDRESS: Des Moines,IA 50306.9686 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Illinois National Ins Co 23817 INSURED INSURER B: ADP TotalSource CO XXI,Inc. INSURER C: 5800 Windward Parkway INSURER D: Alpharetta,GA 30005 Alternate Employer: INSURER E: SOUTH FLORIDA ENGINEERING AND CONSULTING LLC INSURER F: 30 S M ST Lake Worth,FL 03346 COVERAGES CERTIFICATE NUMBER: 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INSR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR INSR WVD (MM/DD/YYYY) (MM/DD/YYYY) COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE TO RENTED PREMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL S ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S POLICY PRO JECT I LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ —OWNED SCHEDULED BODILY INJURY(Per accident) $ _AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE ^ E.L.EACH ACCIDENT $ 2,000,000 • OFFICER/MEMBER EXCLUDED? I I NIA X WC 034274994 FL 07/01/2023 07/01/2024 A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 f yes,describe under DESCRIPTION OF OPERATIONS below E L.DISEASE-POLICY LIMIT S 2,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) All worksite employees workingfor SOUTH FLORIDA ENGINEERING AND CONSULTING LLC paid under ADP TOTALSOURCE,INC.'s payrol are covered under the above stated policy.SOUTH FLORIDA ENGINEERING AND CONSULTING LLC is an alternate employer under this policy.WAIVER OF SUBROGATION IN FAVOR OF CERTIFICATE HOLDER AS RESPECTS OF JOB PERFORMED BY SOUTH FLORIDA ENGINEERING AND CONSULTING LLC AS REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CANCELLATION City of Okeechobee, ATTN:Gary Ritter SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE "55SEThirdAvenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Okeechobee,FL 34974 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE T �Q ACORD 25(2016/03) ©1988-2015 ACORD CORPO ION. All rights reserved. The ACORD name and logo are registered marks of ACORD WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT This endorsement changes the policy to which it is attached effective on the inception date of the policy unless a different date is indicated below. This endorsement, effective 12:01 AM 07/01/2023 forms part of Policy No.WC 034274994 FL Issued to ADP TotalSource CO XXI, Inc. 5800 Windward Parkway Alpharetta, GA 30005 Alternate Employer: SOUTH FLORIDA ENGINEERING AND CONSULTING LLC 30 S M ST Lake Worth, FL 03346 By Illinois National Ins Co We have the right to recover our payments from anyone liable for an injury covered by this policy.We will not enforce our right against the person or organization named in the Schedule. This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us. This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule. Schedule ANY PERSON OR ORGANIZATION TO WHOM YOU BECOME OBLIGATED TO WAIVE YOUR RIGHTS OF RECOVERY AGAINST, UNDER ANY CONTRACT OR AGREEMENT YOU ENTER INTO PRIOR TO THE OCCURRENCE OF LOSS This form is not applicable in Kansas for private construction contracts as defined in K.S.A. 16-1801 through K.S.A. 16-1807 or public construction contracts as defined in K.S.A. 16-1901 through 16-1908, except where permitted by statute or other applicable law, such as for use in wrap-up insurance programs. Any person or organization for which the employer has agreed by written contract, executed prior to loss, may execute a waiver of subrogation. However, for purposes of work performed by the employer in Missouri, this waiver of subrogation does not apply to any construction group of classifications as designated by the waiver of right to recover from others (subrogation) rule in our manual. This form is not applicable in California, Kentucky, New Hampshire, New Jersey, Texas, or Utah. WC 00 03 13 Countersigned by (Ed. 04/84) Authorized Representative