CERTIFICATE OF INSURANCE (27)
ACORDN CERTIFICATE OF LIABILITY INSURANCE OP 10 F~ DATE (MMIDDIYYYY)
DKSAS 1 05/02/05
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Jenkins/Athens Ins Sacramento ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
License No. 0545478 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. O. Box 13847 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Sacramento CA 95853
Phone: 916-925-2525 Fax: 916-925-3595 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Hartford Fire Insurance Co.
, INSURER B: Twin City Fire Ins Co
OKS Associates INSURER c' Alea North America Ins Co
1956 Webster Street #300 INSURER 0: Zurich American Insurance Co
Oakland CA 94612
INSURER E
COVERAGES,
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSRi POLICY NUMBER PO~~1 EFFEC~E I Pgk!fEYI~~b~~N LIMITS
LTR TYPE OF INSURANCE DATE MMIDDIYV
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
f-- 05/01/05 05/01/06 u"'vo~~~ ~ 'c.."<:" I <:u
A X ~ COMMERCIAL GENERAL LIABILITY 57CESOA4976 PREMISES (Ea occurence) $ 300,000
h CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 10,000
,~ $lMM Stop Gap PERSONAL & ADV INJURY $ 1,000,000
--
GENERAL AGGREGATE $2,000,000
f--
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $2,000,000
Jfl'nPRO- n Emp Ben. 1,000,000
X POLICY JECT LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000
A ~ ANY AUTO 57UENOA4977 05/01/05 05/01/06 (Ea accident)
- ALL OWNED AUTOS BODILY INJURY
(Per person) $
SCHEDULED AUTOS
-
- HIRED AUTOS BODILY INJURY
(Per accident) $
NON-DWNED AUTOS
-
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=i ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXeESSIUMBRELLA LIABILITY EACH OCCURRENCE $1,000,000
B :!J OCCUR 0 CLAIMS MADE 57HUSL7684 05/01/05 05/01/06 AGGREGATE $ 1,000,000
$
~ DEDUCTIBLE $
X RETENTION $10,000 $
WORKERS COMPENSATION AND 05/01/051 X I TORY LIMITS I I OJ~-
C EMPLOYERS' LIABILITY WC1045028 I 05/01/06 E.L. EACH ACCIDENT $ 1000000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? , I E.L. DISEASE - EA EMPLOYEE $ .. . 10.0.0.000
if yes, describe under E.L. DISEASE - POLICY LIMIT $ 1000000
SPECIAL PROVISIONS below
OTHER I
0 Professional EOC675855711 05/01/05 05/01/06 Per Claim $1,000,000
Liabilitv Aqqreqate $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Re: City of Clearwater Engineer of Record, A03xOB-00B. The certificate
holder is an additional insured per the attached Form GN201013 0393. 10 day
notice of cancellation will apply if cancelled for non-payment of premium.
CERTIFICATE HOLDER
CANCELLATION
CLEAR-l SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Engineering Dept. , Ste. #220 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
Attn: Susan Chase IMPOSE NO OBLIGATION OR LIABILiTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
P.O. Box 4748
Clearwater FL 3~758-4748 REPRESENTATIVES,
AtFIZEDR~
ACORD 25 (2001/08)
@ACORDCORPORATION 1988
.
'-
Policy Number: 57CEASOA4976
Effective Date: May 1, 2005
.
Named Insured and Address: DKS Associates
1956 Webster St., Suite #300
Oakland, CA 94612
Endt. No.
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS (FORM B)
SCHEDULE
Name of Person or Organization:
City of Clearwater
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of your ongoing operations performed for that insured.
Form GN 20 10 13 (ED. 03/93) Printed in U.S.A. (NS)
@ 1993, The Hartford
(Includes copyrighted material of Insurance Services Office
with its permission, Copyright Insurance Services Office, 1992)