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CERTIFICATE OF LIABILITY INSURANCE (138)Client#: 39357 HWLOC ACORD CERTIFICATE OF LIABILITY INSURANCE fYYYY) DATE - 5/ 03/2010 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. 353 N. Clark Street Chicago, IL 60654 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURER A: Travelers Indemnity Co, of Amer 25666 H. W. Lochner, Inc. INSURER B: St. Paul Fire & Marine Insuranc 24767 20 N. Wacker Drive, Suite 1200 INSURER C: Charter Oak Fire Insurance Comp Chicago, IL 60606 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. NS LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE TE /DD1Y POLICY EXPIRATION DATE MM/DD/YY LIMITS A GENERAL LIABILITY 6608451 B877TIAl0 05/01/10 05/01/11 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY D PREMISES (Ea occurrence) AMAGE TO RENTED $1,000,000 CLAIMS MADE ? OCCUR MED EXP (Any one person) $?j 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 PROECT LOC J C AUT OMOBILE LIABILITY 8108451 B877COF10 05101/10 05/01/11 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $1.000.000 ALL OWNED AUTOS ECENE BODILY INJURY SCHEDULED AUTOS (Per person) $ X HIRED AUTOS 1120 BODILY INJURY X NON-OWNED AUTOS MAY (Per accident) $ X Drive Other Car AND PROPERTY DAMAGE (*F E accident) $ GARAGE LIABILITY t&%p E) L Iff AUTO ONLY • EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ B EXCESS/UMBRELLA LIABILITY QK01202385 05/01/10 05/01/11 EACH OCCURRENCE $5,000,000 X OCCUR ? CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE $ X RETENTION $ 10000 $ A WORKERS COMPENSATION AND PHUB8976P38710 05101/10 05/01111 I TORY WC LIMIT OTH- X EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXE=CUTIVE E.L. EACH ACCIDENT $1,000,000 -"XCLUIJE[D7'."Y. E.L. DISEASE- EA EM _PLOYEE $1 ??O OOI? -- If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $1,000,000 OTHER DESCRIPTION OF OPERATIONS ! LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT! SPECIAL PROVISIONS Re: Engineering Services Contract. The following are included as Additional Insureds on the General Liability Policy per written contract: City of Clearwater. A Waiver of Subrogation applies to the Workers Compensation Policy per written contract. GtK I IF'IGA I t HULUER City of Clearwater City Clerk 100 South Myrtle Ave. Clearwater, FL 33756 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL A_ 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 (2001108) 1 of 2 #S740083/M737266 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 25S (2001/08) 2 of 2 #S740083/M737266 r-Hanrlt- 404S7 LIWI nr AC&D CERTIFICATE OF LIABILITY INSURANCE DATE (MM/D ) ,M 5/ 03/2010 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. 353 N. Clark Street Chicago, IL 60654 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Travelers Indemnity Co. of Amer 25666 H. W. Lochner, Inc. INSURER B: St. Paul Fire & Marine Insuranc 24767 20 N. Wacker Drive, Suite 1200 INSURER C: Charter Oak Fire Insurance Comp Chicago, IL 60606 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MMlDDNY POLICY EXPIRATION DATE MMlDOrfY LIMITS A GENERAL LIABILITY 6608451 B877TIAl0 05/01110 05101/11 EACH OCCURRENCE $1 000 000 X COMMERCIAL GENERAL LIABILITY 70 RENTED PREMI'f ES (Ea occurren rj $1,000,000 _ CLAIMS MADE OCCUR MED EXP (Any one person) $5,000 "- " PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $22000,000 POLICY X PROECT LOC J C AUTOMOBILE LIABILITY 8108451 B877COF10 05/01110 05/01/11 X COMBINED SINGLE LIMIT (Ea accident) $1,000,000 ANY AUTO ALL OWNED AUTOS BODILY INJURY ? $ SCHEDULED AUTOS ??? (Per person) X HIRED AUTOS BODILY INJURY T $ X NON-OWNED AUTOS h (Per accident) OAy 10 2010 X Drive Other Car PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY I L IAL Wa AUTO ONLY - EA ACCIDENT $ ? ' C?+ + LEGI TK SR VCS DEPT ANY AUTO J EA ACC OTHER THAN $ AUTO ONLY: AGG $ B EXCESSIUMBRELLA LIABILITY QK01202385 05101/10 05/01/11 EACH OCCURRENCE $5,000,000 X OCCUR D CLAIMS MADE AGGREGATE s5,000,000 DEDUCTIBLE $ X RETENTION $ 10000 $ A WORKERS COMPENSATION AND PHUB8976P38710 05/01/10 05/01/11 X OR LIMIT 0TH- EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1 000,000 ? A EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE -POLICY LIMIT $1000 000 OTHER DESCRIPTION OF OPERATIONS ! 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) 6=111 I IrIUA I C KULUtK CANUELLA I IUN 7 U UaVS Tor Non-vavmenL 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 Ap_ 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 REPRESENTATIVE ACORD 25 (2001/08) 1 of 3 #S740082/M737266 KI9 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 (2001/08) 2 of 3 #S740082/M737266 ........ ........ . DESCRIPTIONS (Continued front 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 #S740082/M737266