2007 SANITARY SEWER & MANHOLE REHABILITATION PROJECT - 07-0015-UT - CERTIFICATE OF LIABILITY INSURANCE
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CONSTRUCTION SERVICES
410 N. Myrtle Ave., 33755
PO Box 4748, Clearwater, FL 33758-4748
Phone: (727) 462-6l26, Fax: (727)462-6989
TRANSMITTAL FORM
TO:
Official Records & Legislative Services
Attn: Susan Chase, City Clerk Specialist
Re:
Current Certificate of Liability
Insurance
Date: June 3, 2008
WE ARE SENDING TO YOU
181 ATTACHED 0 UNDER SEPARATE COVER VIA
THE FOLLOWING ITEMS:
o Shop Drawings
o Copy of Letter
o Prints
o Change Order
o Plans
o Specifications
o Samples
o As Requested
COPIES DATE NO. DESCRIPTION
1 OS/28/08 1 Attached COpy of "Current Certificate of Liability Insurance" for JTV, Inc.
THESE ARE TRANSMITTED AS CHECKED BELOW:
o Approved as noted
o Return _ corrected prints
o
o
o For approval & payment
o As requested
o
o
o Approved as submitted
o For review and comment
o
o
ROUTE
DATE RECEIVED DATE REVIEWED
INITIALS & COMMENTS
REMARKS: Attached Current Certificate of Liability Insurance for your information. JTV,
Inc. was awarded a portion of the Annual Contract for the 2007 Sanitary Sewer &
Manhole Rehabilitation Project (07-0015-UT)
SIGNED: _~..~.. . ~
Alice Eckman, Construction Office Specialist
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Please notify us if attachments are not included
Thank you for your business
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cc: Kathy Bedini, Staff AssistantlEngineering (Copy of Certificate)
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A CORDTM CERTIFleATE OF liABILITY INSURANCE DATE (MM/DDIYYYY)
6/15/2007
PRODUCER (727) 391-9791 FAX: (727) 393-5623 THIS CERTIFICA TEIS ISSUED AS A MATTER OF INFORMATION
Stahl & Associates Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
110 Carillon Parkway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
St. Petersburg FL 33716 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A FCCI Insurance Company 12842
JTV, Inc. INSURER B: FCCI Commercial Insurance 12842
ID # 380357 INSURERC:Associated Industries Ins 23140
POBox 28397 INSURER D:
St Petersburg FL 33709 INSURER E:
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 r.LAIM~.
INSR ADD'L POLICY NUMBER P~A~~:~~g8Mf Pg~WI~~~N LIMITS
TYPE OF INSURANCE
GENERAL LIABILITY EACH ""CURRENCE $ 1,000,000
'-- ~~~~H?E~~~~~ence)
X COMMERCIAL GENERAL LIABILITY $ 100,000
A I CLAIMS MADE ~ OCCUR CPPOOO45604 1/21/2008 . 1/21/2009 MED EXP IAnv one oerson) $ 5,000
- PER!:ONAL & ADV INJURY $ 1,000,000
- GENERAL AGGREGATE $ 1,000,000
GEN'lAGGREGATE liMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000
Xl POLICY n ~~T n lOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $ 1,000,000
~ ANY AUTO (Ea accident)
A ALL OWNED AUTOS CAOOO55414 1/21/2008 1/21/2009 BODilY INJURY
- (Per person) $
- SCHEDULED AUTOS
~ HIRED AUTOS BODilY INJURY
$
~ NON-OWNED AUTOS (Per accident)
p
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACe: $
AUTO ONLY: AGG $
EXCESSlUMBRELLA LIABILITY <=A,." $ 1,000,000
~ OCCUR o CLAIMS MADE UMBOOO5994 AGGREGATE $' 1,000,000
$
B ;1 DEDUCTIBLE OVER GENERAL LIABILITY 11/20/2007 11/20/2008 $
.- -- X RETENTION 9: 10,000 - ONLY ..... . -. $ .- --,- -
C WORKERS COMPENSATION AND X I T~JmI,~" I IOJ~-
EMPLOYERS' LIABILITY 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E,l. EACH ACCIDENT $
OFFICERlMEMBER EXCLUDED? AWC1OOO788 3/24/2008 3/24/2009 E.l. DISEASE - EA EMPLOYEE $ 500,000
~ yes, describe under 500,000
SPECIAL PROVISIONS below E.l. DISEASE - POLICY LIMIT $
OTHER
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DESCRIPTION OF OPERATIONSlLOCATlONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS ~ r.,-.. ....,. ".-
Workers Compensation Policy includes Florida Safety Premium & Drug Free Workplace credits - '
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CERTIFICATE HOLDER CANCELLATION pU,"',' - ') \......\
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
City of Clearwater EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Attn: Edward Burke 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
1650 N Arcturas -
Clearwater, FL 33765 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE ~~ ~
Kelly Petzold/NANCR2 f?~~
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ACORD 25 (2001/08)
INS025 (0108).08a
@ ACORD CORPORATION 1988
Page 1 012
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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),
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
~ .
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
INS025 (0108).08a
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