CERTIFICATE OF LIABILITY INSURANCE (80)Client: 39357
ACORU. CERTIFICATE OF LIABI
PROWCER
Construction - Remegi Team
Mesirow Insurance Service
321 N. Clark Street
Chicago, IL 60654
INSURED
H. W. Lachner,-Inc.....__....
20 N. Wacker Drive
Chicago, IL 60606
HWLOC
DATE
DmYY)
LITY INSURANCE
04
/27/09
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 NAIC #
INSURERA: Travelers Indemnity Co.'ofAmerica 25666
INSURER B: Commerce 8r Industry
INSURER C: Charter Oak Fire Insurance Company
INSURER D: ..
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.
S ADD'N POLICY EFFECTIVE POLICY EXPIRATION
LTR NS TYPE OF INSURANCE POLICY NUMBER DATE M DATE LIMITS
A GENERAL LIABILITY P6508451 B877TIA09 05/01/09 05101/10 EACH OCCURRENCE $1,000.000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1,000,000 ocel CLAIMS MADE Fx? 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 $2 000 000
POLICY X PRO-
F
LOC
CT F
C AUTOMOBILE LIABILITY P8108451 B877COF09 05/01/09 05/01/10 COMBINED SINGLE LIMIT
X ANY AUTO (Ea accident) $1,000,000
ALL OWNED AUTOS --
BODILY INJURY $
SCHEDULED AUTOS I , (Per person)
ED AUTOS ! ?y BODILY INJURY
n _ .....
D AUTOS (Per accident) $
X
$.
PROPERTY DAMAGE
GARAGE LIABILITY .r . AUTO ONLY -EAACCIDENT $ -::-:.- -
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY, AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
71 OCCUR FICLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
RETENTION $ $
B WORKERSCOMPENSATION AND WC5323324 05/01/09 05/01/10 X
I TORY WC LIMIT O R
EMPLOYERS' LIABILITY
T
OFFICER/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 I LOCATIONS / 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)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater Attn: City DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 _ DAYS WRITTEN
Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
P.O. Box 4748 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Clearwater, FL 33758.4748 REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
A
ACORD 25 (2001/08) 1 of 3 #M562396 KI9 0 ACORD CORPORATION 1988
if-
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 (2001/08) 2 of 3 #M562396
- 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 (2001/08) 3 of 3 #M562396