BEACH WALK PHASES II, III & IV (03-0079-ED) - CERTIFICATE OF LIABILITY INSURANCE
~
..Al.,Ut(~ \;I:K ..t-.\;A II: U" LIAtSlLl1 IN~UKAN\;I: I 05/14/2007
PRODUCER (813) 18Z-1965 FAX (888)883-8688 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORtlIATION
Lassiter-ware Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CER~TE DOi:nNOT AMEND, EXTE~cr
5600 Mariner Street ALTER THE COVERAG . AFFORD BY THE POLICIES B OW.
Suite 2IS
Tampa II FL 33609 WSURERSAFFORaNGOOVERAGE NAlC#I
INSURED David NelsOll COIIstructJOIJ Co. INSlJRER ,. NatiOllal Fire IIJS Co of Ha Z0478
3483 Alternate 19 N INSURER B: National UniOll Fire Ins Co 19445
Palm Harbor II FL 34683 INSURER C:
INSURER D:
INSURER E:
THE POliCIES OF INSURANCE LISTED BElOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWITHSTANDlNG
/W'{ REQUIREMEI\rr, TERM OR CONDmON OF Nt( CONTRACT OR OTHER DOClJMENrWJTH RESPECT" TO \/\IHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SU8JECTTO AlllHE TERMS, EXClUSIONS AND CONDmONS OF SUCH
POlICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REOOCED BY PAID ClAIMS.
~ lYPE OF INSURANCE POLICY NUMBER pOLlCY EFFECTI\/E ecPRAllON LMTS
GENERAl. UABl\.J1Y 2077389332 05/01/Z007 05/01/2008 EACH OCCURRENCE $ 1.000.00(
-,-::- DAMAGE TO REtffiOD 1001lOiii.
X COMMERCIAl GEJlERAl LIABUTY $
1 CLAIMS MADE [!] OCCUR MED EX? (Any one person) $ 51100l
A ..!- XClJ Inc 1 udell PERSONAL & ADVINJURY $ 1.000. r.JO(
GENERAL AGGREG"'TE $ 2,000. IJO(
- !HHl
GEN'L AGGREGATE LMT' APPLIES PER PRODUCTS. COMPIOP Aoo $ 1.000.-
I POUCY fXl ~ nLOC
~OMOSlLE LIABIUlY 2077538029 05/01/2007 05/01/1008 COMBINED SINGlE LlMrr
(Ea acciderdl $ l,OOO.ootJ
X ANY AUTO
I--
ALL OWNED AUTOS .,
i-- BOOIl Y INJURY $
SCHEDULED AUTOS (perpersom
A X
HIRED AUTOS BOD1l. Y INJURY
Y $
NON-OWNED AUTOS (per accident)
..:...:..
PROPERT'I DIIMAGE $
(Per attid<mt)
GARAGE LIASlIJ'TY AUTO ONl.. Y - EA ACCIDENT $
=1. "'NY AUTO OTI-lERTI-lAN EA ACC $
AUTO ONl.. Y: "'00 $
EXCESSIUMSRELLA LIA8lIlIY HEN OF BE65644D2 05/01/Z007 05/01/1008 EACHOCClJRRENC,," $ 10.000.~
o OCCUR D a.A1MS MADE AGGREGATE $, 20,000. DOl.
B $
~ DEDUCllBLE RECEI\ 'ED $
X REIDl110N $ 10,OfH $
WORKERS COMPENSATION AND t,~~Y '"': ~... " 007 I ~;r;~J.1fs I 10m-
ENPLOYCRlr UABLITY
ANYPROPRIETORIPARlNERiEXECUTIVE I ( ~ J, <j t. EL EACH ACCIDENT $
OFFlCERJMEMBER EXCLUDED? E.L, DISEASE - EA EMPLOYEE $
W vas, destribe under OF FICW REC()C ....~ ^"II".
SPECIAL PROVISIONS beloW EL DISEASE. POUCY LIMIT $
OTHER lE =,ISLATIVE SRV( S DEPT
~OFOPERAT\ONSILfrllONSlvallCU!S'exCLU8lDNS:rfBY~'SPEClAL~ ONner and any other persons
roject: Beach Ita k Phasess ZII 3, iIII 4 (03-00 '9-ED). CIty of Oearwater, lor entities, respective officers & employees required by written contract are nallled as Additional
Irnsureds with respects to General Liability & AutOllfObile HabHity polides. this insurance evidenced
Iby this certificate is prirtaryto any other insurance of the additional jnsureds.
~ee Attached Notes.
.rullI. OOO-oo.:1-QUOU
I U. J' L ,"tu..tucnmr
riG. .Q:...J
LJ'ClLCi. WI ...,,,,,uvt ,\J....".~ In"'"
C
ATEH
N
SHOULD ANi OF THE ABOVE DESCRIBED POLICIES BE CANCElLED BEFORE THE
EXPRAllON DATE THEREOF, THE ISSUING INSUREItWILI. ENDEAVORTOMAIL
-31L DAYSWRmEN NOTICE TO THE CERTIFICATE HOLpeRI\IAMED TO THE LEFT.
BllTFAlLURETO MAJLSUCH N01ICE SHALL IMPOSE NO OBLIGAtION ORUABII.I1't
OF 11<< KIND UPON THE INSURER, ITSAGENT'S ORREPRESENTATM:S.
AUlHORIZED REPRESENTATNE
~~~
City of Clearwater
AttlJ: AHce R. Eckman
P. O. Box 4748
Oearwater, FL 33758-474&
Kirk Bramlett STELLA
ACORD25(2001/DB) FAX: (721)46Z-6989
@ACORD CORPORATION 1988
rIUIII.~
IV. .'IL'~
r a~. oJ#oJ
LJaLV. VI '~"U\J' IV._,""~ t , ...t
.~
IMPORTANT
If the certificate holder is an AOOmoNAlINSURED, the poficy(teS) 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 iD the terms and conditions of the policy, certain policies may
requir.e an endorsement A statement on this certificate does nat 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 (2001108)
rronn:~
I U. I t Lt "ULU<OU<O
....CIl:IC. -."./
LJCIL~. ...n .-"LUVI 'U.W'.~ nlV'
fldd;~;onal Coverages and Fac~ors
04/30/2007
.ine of Business Coverages for
:overage
lIP-Basi c
:omprehensive
:ol1ision
led; ca 1 payments
Ininsured motorist 81-
.ingle limit
:ombined single lilllit
Mise Info: BI/PO
'011 uti on Buyback
.ine of Business Coverages for
:over-age
'roducts/Completed Ops
.ggregate
lersonal & Advertising
:njury
:ach Occurrence
:; re Damage
led; ca 1 Expense
;eneral Aggregate
mployee Benefits
:mployee Benefits
Business Auto
Lillits
1,000
1,000,000
1,000,000
1,000,000
General liability
Lillits
2,000,000
1,000,000
1,000,000
100,000
5,000
2,000,000
1,000,000/2 ,000,000
1,000,000/2,000,000
DedjDed Type
Rate
l,OOO/Per Accident
Ded/Decl Type
Rate
PreIlium
Factor
PrelliURI
Factor
5,000
Basis: Per Occurrence; Applies: Property
1,000
r-rUrTl.OOO-oo,,>-OOOU
JU. 1I~'''U4:~
r-~. Wlv
&JcILC....n .""':UUI IV.vL.~ ,...,W.
c;~ of Clearwater
f':erti ficate issued to City of Clearwater 05/14/2007
.assiter-Ware Insurance
1S/14/2007
laiver of Subrogation applies in favor of City of Clearwater, Owner and any other persons or entities,
'espective officers & employees required by written contract with res.pects to General Liability &
.utOlllObile liability policies. 30 days cancellation notice except 10 days for non-payment only applies to
ieneral Liability & Automobile liability policies.
This certificate is executed b Libe Mutual Insurance Grou as res ects such insurance as is afforded b those com 'es. BM0068
Certificate of Insurance
This certificate is issued as a matter of information only and confers no rights upon you the certificate holder. This certificate is nol an insurance policy and does nol amend, extend, or alter the coverage
afforded b the olicies listed below.
This is to certify tbat (Name and address ofInsured)
f.,... .:~ Libertx
\p MutuatM
DAVID NELSON CONSTRUCTION CO.
3483 ALT 19 NORTH
PALM HARBOR, FL 34683
is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the listed policy(ies) is subject to all their terms, exclusions and conditions and
. di . f th d .th hi h this'fi be' ed
is not altered bv anv reQUU'ernenl. term or con bon 0 any conbacl or 0 er ocwnent WI respect to w c certl. cate may ' lSSU
Expiration Type EffJE:lD. Datds) Policy Numberls) Limits of Liability
Continuous* 01/0112007/01/0112008 WC2-151-271119-247 Coverage afforded under WC law of Employers Liability
I-- the followi~ states:
I-- Extended Bodily Injury By Accident
X Policy Term FL $500,000 Each Accident
Bodily Injury By Disease
$500,000 Policy Limit
Workers Compensation Bodily Injury By Disease
$500,000 Each Person
General Aggregate-Other than Prod/Completed Operations
General Liability
Products/Completed Operations Aggregate
H Claims Made
Occurrence Bodily Injury and Property Damage Liability Per
Occurrence
I Retro Date I Personal and Advertising Injury Per Person I
Or2anization
Other Liability I Other Liability
Each Accident - Single Limit - B. I. and P. D. Combined
Automobile Liability
Each Person
- Owned
Non-Owned Each Accident or Occurrence
-
Hired
Each Accident or Occurrence
C RE: Beach Walk Phases 2,3,4 (03-OO79-ED). This Insurance evidenced by this certificate is primary to any other insurance.
0
M
M
E
N
T
S
.If the certificate expiration date is continuous or extended term. you will be notified if coverage is terminated or reduced before the certificate expiration date. However, you will not be notified annually of
the continuation of coverage.
Special Notice - Ohio: Any person who, with intent to deftaud or knowing that he I she is faciIitating a fraud against an insurer, submits an application or files a claim containing a false or
deceptive statement is guilty of insurance ftaud.
Important information to Florida policyholders and certificate hold...: in the event you have any questions or need information about this certificate for any reason, please contact your local sales producer,
whose name and telephone number appears in lbe lower left comer of this certificate. The appropriate local sales office mailing address may also be obtained by calling this number.
Notice of cancellation: (not applicable unless a number of days is entered below). Before the stated expiration date the company will not cancel or reduce the insurance afforded under the above
policies until at least 30 days notice of such cancellation has been mailed to:
Office: TAMPA, FL Phone: 813-264-6588 ~~~~
Certificate Holder: AUDREY ACCETTA
City of Clearwater Autborized Representative
PO Box 4748
Clearwater, FL 33758
Date Issued: 12/28/2006 Prepared By: IS
ACIJB.Ct CERTIFICATE OF LIABILITY INSURANCE
~ (813)28 :196
Lassiter-Ware Insurance
5600 Mariner Street
Suite 215
Tampa, FL 33609
INSURED aVl Ne son Constructlon ~ny
3483 Alternate 19 N
Palm Harbor, FL 34683
FAX (813)282-9374
DAle (MMIDDIYYYYl
12/20/2006
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE
INSURERA: National Fire Ins Co of Ha
INSURER B: Vall ey Forge Insurance
INSURERC: National union Fire Ins Co
NAIC#
20478
20508
19445
INSURER 0:
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 MAYBE 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 SHO\I\IN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DO' TYPE OF INSURANCE POlICY NUMBER POUCY EFFa:TIYE POlJCY EXPtRAllON LIMITS
GENERAL LlABn..1TY 2077389332 05/01/2006 05/01/2007 EACH OCCURRENCE $ 1,000,000
- DAMAGE TO RENTED 100,000
~ COMMERCIAL GENERAL LIABILITY $
=:J CLAIMS MADE m OCCUR MED EXP (Anyone person) $ 5 , 000
A X XCU Included PERSONAL & ADV INJURY $ 1,000,00
GENERAL AGGREGATE $ 2.000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000.00C
"I POLICY m ~8T n LOC
AUTOMOBILE LIABILITY 2077538029 05/01/2006 05/01/2007 COMBINED SINGLE LIMIT
X ANY AUTO (Ea 1ICCident) $ 1,000,00(
-'-
ALL O\'\INED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
B X
HIRED AUTOS BODILY INJURY
X $
NQN..()\'\INED AUTOS (Per accident)
-
PROPERTY DAMAGE $
(Per accident)
GARAGE lIABILITY AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSlUMIlllEU.A LIABILITY BE6564402 05/01/2006 05/01/2007 EACH OCCURRENCE $ 20,000,000
~ OCCUR D CLAIMS MADE AGGREGATE $ 20,000,000
C $
~ DEDUCTIBLE S
RETENTION S $
WORKERS COMPENSA l10N AND WC2081445946 01/01/2006 01/01/2007 X I we STATU- I IOJ~-
EMPlOvas' LIABILITY 500,000
B ANY PROPRIETORIPARTNERlEXECUTIVE E.L. EACH ACCIDENT S
OFFICERlMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE S 500,000
~~~I~~V~~S below E.L. DISEASE - POLICY LIMIT $ 500.000
OTHER
oesq,R1PTtON OF OPERA~~11ONS/\lEHlCLES/EXCLU:3'1^m BY ~ ISPECIAL~S
'roJect: Beach Wa asess 2, 3, an 4 03-oo79-ED. City 0 earwater, Owner and any other persons
)r entities, respective officers . ~loyees required by written contract are named as Additional
nsureds with respects to General Liability. AutOMObile liability policies. This insurance evidenced
,y this certificate is primary to any other insurance of the additional insureds.
iee Attached Notes.
nCD -A nON
SHOULD AI<< OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAil
~ DAYS WRITTEN NOTICE TO THE CERTlFICAlE HOLDER NAMED TO THE LEFT,
City of Clearwater BUT FAl.URE TO MAL SUCH NOnce SHALL IMPOSE NO OBUGATlON OR LlABIUTY
P.O. Box 4748 OF AI<< Qft) UPON THE INSURER, ITS AGENTS OR REPRESENTA11VES.
Cl earwater, FL 33758-4748 AUntORIZED REPRESENTATIVE ~
Kirk Br_lett/STELLA ;;-'~~-
. - -/- - .
. ACORD 25 (2001108)
@ACORD CORPORATION 1988
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 ofthe 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.
CORD 25 (2001/08)
Additional Coverages and Factors
04/27/2006
4IIle of Business Coverages for
Business Auto
Coverage Limits
PIP-Basic
Comprehensive
Collision
Medical payments 1,000
Uninsured motorist BI- 1,000,000
single limit
Combined single limit 1,000,000
Misc Info: BI/PO
Pollution Buyback
line of Business Coverages for
Coverage
Products/Completed Ops
Aggregate
Personal & Advertising
Injury
Each Occurrence
Fire Damage
Medical Expense
General Aggregate
Employee Benefits
4lirlOyee Benefits
Line of Business Coverages
1,000,000
General L iabili ty
limits
2,000,000
1,000,000
1,000,000
100,000
5,000
2,000,000
1,000,000/2,000,000
1,000,000/2,000,000
Oed/Ded Type
Rate
1,000/Per Accident
0ed1Ded Type
Rate
Premi um
Premium
5,000
Basis: Per Occurrence; Applies: Property
1,000
for Workers Compensation
Coverage Li.nts
Expense constant
we & Employer's liability 500,000/500,000/
500,000
Increased employer's
liability
Safety Credit
Premium discount
Drug Free Credit
Surcharges
Terrorism
Adjst. to reconcile-exp
mod. premi urn
Assigned risk add'l
premium
.
Oed/Ded Type
Rate
Premi um
200.00
2,470.00
-6,225.00
-29,600.00
-15,251.00
1,362.00
-5,795.00
-31,237.00
Factor
Factor
Factor
0.00800
0.02000
0.05000
0.98000
C; ty of C1 earwater
CertU;cate ;ssued to C;ty of Clearwater 12/20/2006
Lass;ter-Ware Insurance
_0/2006
er of Subrogation applies in favor of City of Clearwater, Owner and any other persons or entities.
ective officers & employees required by written contract with respects to General Liability.
Automobile liability & Workers Compensation policies. 30 days cancellation notice except 10 days for non-
payment only applies to General Liability & Automobile liability policies.
.
.