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CERTIFICATE OF LIABILITY INSURANCE (75)Client#: 39357 HWLOC A C ORDTM CERTIFICATE O F L I A B I L I TY I N S U RA N C E DATE (M MIDDIYYYY) 10114108 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Construction - Remegi Team ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Mesirow Insurance Service HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 321 N. Clark Street Chicago, IL 60610 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: TrayelerS Indemnity Co. of America 25666 H. W. Lochner, Inc. INSURER B: Illinois National Insurance Company 20 N. Wacker Drive INSURER C: Commerce & Industry Chicago, IL 60606 INSURER D: Phoenix Insurance Company 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. INSR LTR DD' NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMIDDIYY POLICY EXPIRATION DATE MMIDDIYY LIMITS A GENERAL LIABILITY Y6608451 B877TIA08 05?01?08 05101109 EACH OCCURRENCE $1 QQQ QQQ X COMMERCIAL GENERAL LIABILITY PREM SES? a occur ence $250 000 CLAIMS MADE ? OCCUR MED EXP (Any one person) $5 QQQ PERSONAL & ADV INJURY $1 QQQ QQQ GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $2,000,000 POLICY X PRO- LOC JECT D AUTOMOBILE LIABILITY Y8108451 B877PHX08 05?01?08 05101109 COMBINED SINGLE LIMIT (Ea accident) $1 ???????? X ANY AUTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC OTHER THAN $ AUTO ONLY: AGG $ B EXCESSIUMBRELLA LIABILITY BE7251567 05?01?08 05101109 EACH OCCURRENCE $5 ??? ??? X OCCUR ? CLAIMS MADE AGGREGATE $5 ??? ??? DEDUCTIBLE $ X RETENTION $ 10000 $ C WORKERS COMPENSATION AND WC2953807 05?01?08 05101109 X WC STATU- OTH- TORY LIMITS ER EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Re: City of Clearwater Job #2289 -Gas Design and permitting for US 19 (FPID #256881-1 and 256881-2) Job #2306 -Gas Design and permitting for US 41 (FPID #256324-1) (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: City Clerk P.O. Box 4748 Clearwater, FL 33758-4748 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ?„Q_ 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 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08)1 of 3 #S5324211M506811 SXJ 0 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 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 #S5324211M506811 DESCRIPTIONS (Continued from Page 1) Job #2413 -Gas Design and permitting for US 41 (FPID #418860-2) Job #2769 -Gas Design and permitting for US 41 (FPID #403725) Job #2785 -Gas Design and permitting for US 41 (FPID #257131) Job #2860-SR 52 Suncoast to US 41 -Gas Design and Permitting The following is an additional insured as respects General Liability and Automobile Liability as required by written contract. There is also a waiver of subrogation in favor of the following as respects General Liability and Automobile Liability as required by written contract: CITY OF CLEARWATER Severability of interest clause applies to the General Liability per the attached. AMS 25.3 (2001108) 3 of 3 #S5324211M506811 P`_lianlit- '10'1 ;7 WWI nr_ 7AC6RD CERTIFICATE OF LIABILITY INSURANCE DnYYY) DATE . 04/27/09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Construction - Remegi Team ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Mesirow Insurance Service HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 321 N. Clark Street Chicago, IL 60654 INSURERS AFFORDING COVERAGE NAIC # INSUR ED - -. ' ' INSURER A: Travelers Indemnity Co. .of America. 25666 " H W Lochner; Inc . INSURER e: 5t. Paul Fire & Marine Insurance Co.- 24767 ' 20.N. Wacker Dive INSURER C: Commerce & Industry Chicago, IL .60606 INSURER D: Charter Oak Fire Insurance-Company'-' INSURER E: CnVFRAnFR . 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EM 13 CTIVE POLICY EXPIRATION LIMITS A GENERAL LIABILITY P6608451B877TIA09 05101/09 05/01/10 EACH OCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1 000 000 CLAIMS MADE 17X OCCUR MED EXP Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000 POLICY X PR LOC D AUTOMOBILE LIABILITY P8108451B877COF09i'. =051,01/09 05/01/10 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS i . r BODILY INJURY W t I O Per Person) ( $ SCHEDULED AUTOS , ! X HIRED AUTOS ?l BODILY INJURY ' - - $ .. ......... . X NON-OWNED AUTOS . nt . acci . X Drive Other Car - `- _.... PROPERTY DAMAGE _. _.. _. _..-- AGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO - OTHER THAN EA ACC $ - - AUTO ONLY: AGG $ B EXCESS/UMBRELLA LIABILITY QK01202053 05/01/09 05/01/10 EACH OCCURRENCE $5,000,000 X OCCUR F1 CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE $ X RETENTION $10,000 $ C WORKERS COMPENSATION AND WC5323324 05/01/09 05/01/10 X OR STATUS OTH-IMITS FIR EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $1,000,000 OFFICE MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000 If yes, describe Under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS Re: City of Clearwater Job #2289 - Gas Design and permitting for US 19 (FPID #256881.1 and 256881-2) Job #2306 - Gas Design and permitting for US 41 (FPID #256324-1) (See Attached Descriptions) 1. r-M 111`IVfi 1 C I'7ULUCK City of Clearwater Attn: City Clerk P.O. Box 4748 Clearwater, FL 33758-4748 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL - 0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE ACORD 25 (2001/08) 1 of 3 #M562389 KI9 © 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 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 #M562389 f DESCRIPTIONS (Continued from Page 1) G Job #2413 - Gas Design and permitting for US 41 (FPID #418860.2) Job #2769 - Gas Design and permitting for US 41 (FPID #403725) Job #2785 - Gas Design and permitting for US 41 (FPID #257131) Job #2860-SR 52 Suncoast to US 41 - Gas Design and Permitting The following is an additional insured as respects General Liability and Automobile Liability as required by written contract. There is also a waiver of subrogation in favor of the following as respects General Liability and Automobile Liability as required by written contract: CITY OF CLEARWATER Severability of interest clause applies to the General Liability per the attached. AM5 25.3 (2001/03) 3 of 3 #M562389