CERTIFICATE OF LIABILITY INSURANCE (149)AC O® DATE (MMIDD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 08/1312010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. 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).
PRODUCER 2 ... Doug Smith
I
Doug Smith
18427 US Highway 41
Q Lutz, FL 33549
INSURED
Kisinger Campo & Associates Corp.
KCCS, Inc
201 N. Franklin St. Ste 400
Tampa, FL 33602
COVFRe(CFS ('FRTIFICeTF NI IMRFR•
?; 813-909-4700 aAIICC. No): 813-909-4470
doug.smith.jitq @statefarm. cam
A246287
INSURER(S) AFFORDING COVERAGE NAIL #
State Farm Mutual Automobile Insurance Company 25178
RFVICIAN NIIMRI=R•
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
IN SR TYPE OF INSURANCE ADDL SUER POLICY NUMBER NI LILY EFF MM/ POLICYEXP
LIMITS
GENERAL LIABILITY EACH OCCURRENCE
_ $
COMMERCIAL GENERAL LIABILITY
RENTEIY
PREMISES Ea
occurrence
$
CLAIMS-MADE F7 OCCUR MED EXP Any one rson $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG s
POLICY PRO- LOC $
AUT OMOBILE LIABILITY a _? 1/2010 09/01/2011 COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
ANY AUTO 922845-001-69 BODILY INJURY (Par person) $
X ALL OWNED AUTOS SEP Q 8 ?? BODILY INJURY (Per accident) $
X SCHEDULEDAUTOS
HIRED AUTOS
pp
c AND
S D PROPERTY DAMAGE
(Per accident) $
X NON-OWNED AUTOS C
OFFICIAL RECO D
y Comprehensive $ 500
LEGISLAWE S ` ICS Dr Collision $ 500
UMBRELLA LLAB OCCUR EACH OCCURRENCE $
EXCESS LIAR H CLAIMS-MADE ? AGGREGATE $
DEDUCTIBLE $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABWTY B TH-
E
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
F
NIA
? E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) E.L DISEASE - EA EMPLOYE $
f yes, de5(gib0 under E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, AddltlonW Remarm Schedule, If more apace la required)
Services under Engineer of Record Agreement, RFQ #12 09 (KCA #6200905.00)
Certificate holder is also an additional insured. The issuing insurer will endeavor to mail 30 days written notice of cancellation to the certificate holder.
CERTIFICATE HOLDER CANCELLATION
City of Clearwater Attn: City Clerk I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
P. 0. Box 4748 EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE
POLICY PROVISIONS.
Clearwater, FL 33758-4748
988- 2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are marks of ACORD 1001486 132849.4 02-11-2010