CERTIFICATE OF LIABILITY INSURANCE (72)f I;--*4f- i,,i,2n7
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ACQRD,M CERTIFICATE OF LIABILITY INSURANCE 12/24
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PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Saginaw Bay Underwriters ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Commercial Lines ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
1258 S. Washington P.O. Box 1928
Saginaw, MI 48605 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Zurich North America - -
R. Roese Contracting Inc. INSURER B: Cincinnati Ins. Co.
P.O. Box 158 INSURER C: Hanover Ins. Co.
Kawkawlin, MI 48631
INSURER D:
- INSURER E:
rnVFRAnPR
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.
INSR
LTR DD'
NSR
TYPE OF INSURANCE
POLICY NUMBER POLICY EFFECTIVE
DATE MM DD/YY POLICY EXPIRATION
DATE MM/DD/YY
LIMITS
A GENERAL LIABILITY GL0914088701 01/01/09 01/01/10 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
P F FS rF c orr
$300,000
- CLAIMS MADE F7X OCCUR MED EXP (Any one person) $10,000
X PD Ded:10,000 PERSONAL & ADV INJURY $11,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000
POLICY PRO LOC
JECT
A AUT OMOBILE LIABILITY BAP914088800 01/01/09 01/01110 COMBINED SINGLE LIMIT
(Ea accident) $1,000,000
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY -
SCHEDULED AUTOS (Per person) $
X HIRED AUTOS
BODILY INJURY ' -
$
X NON-OWNED AUTOS (Per accident)
X Drive Other Car
- PROPERTY DAMAGE-
11 - - (Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY XS1160390 01/01/09 01/01110 EACH OCCURRENCE $5000000
OCCUR XI CLAIMS MADE AGGREGATE $5,000,000
DEDUCTIBLE $
RETENTION $ $
A
WORKERS COMPENSATION AND
WC914088901
01/01/09
01/01/10 WC STATU- OTH-
TORY i iMiT ` 1 EE
- EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT
$100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $100,000
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
$500,000
C OTHER Leased or IHH793266203 01/01/09 01/01/10 $200,000
Rented Equipment $5,000 Deductible
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate Holder and any other persons or entities identified in the
Supplementary Conditions are named Additional Insured with respects to the
General
Liability. Owner and Contractor waive all rights against each other and
(See Attached Descriptions)
It HULDEK
City of Clearwater, City Manager
100 S. Myrtle Ave., 3rd Floor
Clearwater, FL 33756-5520
Af1r%0r% -3C 19AA41AQ% w _c 9 "RAAtl AAne
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
AUTHORIZED REPRESENTA
Avfr n Af'f1R1 r n PPnPATInM'I QRS
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-S (2001108) 2 of 3 #M134196
AMS 25.3 (2001/08) 3 of 3 #M134196