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CERTIFICATE OF LIABILITY INSURANCE (7)ACORD CERTIFICATE OF LIABILITY INSURANCE DA M oY) ,n, 1 27 20 PRODUCER Phone: 727-461-6044 Fax: 727-442-7695 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brown L Brown Insurance - Clearwater ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR P.O. Box 2456 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 660 Clearwater FL 33757-2456 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:National Fire Ins of Hartford Z .Q478 King Engineeri ng Assoc., Inc. INSURERB: Transportation Insurance Co. 20494 4921 Memorial Hwy Ste 300 „ INSURERC:Valley Forge Insurance Com an 0508 Tampa FL 33634 INSURER D: INSURER E: &-r%W00Af2C4_' 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 DD' LTR INSRQ F POLICY NUMBER POLICY EFFECTIVE D POLICY EXPIRATION DATE (MMIDDffY) LIMITS j? X GENERAL LIABILITY C2066728229 1/1/2011 1/1/2012 EACH OCCURRENCE $ 1? QQQ Q00 . X COMMERCIAL GENERAL LIABILITY PREMISES Ea dccurence $566,060 CLAIMS MADE ?X? r-? OCCUR _ MED EXP (Any one person) $5,000 X PERSONAL & ADV INJURY , $ 1 0 0 0 Q Q Q X Contractual Liab GENERAL AGGREGATE $ 2 000 QQQ GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS -COMP/OPAGG $2,000,-Q,00 POLICY X I PRO n LOC A AUT OMOBILE LIABILITY C2066728232 . 1/I/201I 1/1/2012 COMBINED SINGLE LIMIT $ X ANY AUTO (Ea accident) 1,00o, 000 ALLOWNED AUT05 RE ? /rr ED ' E BODILY INJURY $ SCHEDULEDAUTOS a ? Y (Per person) w }{ } ' HIREpAUT05 NON-OWNED AUTOS I DEC' 2 9 2010 BODILY INJURY (Per accident) $ ? PROPERTYDAMAGE $ E CORDS kr G "•3 (Peraccident) GA RAGE LIABILITY GISLAITWE SRV'CS DEF T AUTO ONLY-EA ACCIDENT $ ANY AUTO LE ?•G OTHERTHAN EA ACC -_ $ AUTO ONLY: AGG $ $ EXCESS/UMBRELLA LIABILITY 02066728246 1/1/2011 1/1/2012 EACHOCCURRENCE $ j 000,000 OCCUR CLAIMS MADE r AGGREGATE .$ 5,000,000 I ???? I $ DEDUCTIBLE $ .-„,... X RETENTION $ -, $ C - -WORKER$COMPENSATION AND - WC1_ 63E72015 .1.1./2.011.. ..... 1/1/2U12 bTH- EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ 1 QQQ Q Q Q ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICEWMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1 0 0 0 0 0 0 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ Q Q Q OTHER i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Certificate Holder is additional insured per the terms of the liability policy with respect to Bodily Injury or Property Damage arising from the work performed by the named insured per form 0140331B 01109 (attached). Waiver of Subrogation for General Liability is included in blanket form. * 10 Day Notice for Non Payment of Premium overage is primary & Non Contributory to any policies held by the certificate holder as required by written contract. rFRTIGIreTF unI PRO CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER City of Clearwater WILL ENDEAVOR TO MAIL 30 DAYS* WRITTEN NOTICE TO THE Attn: City Clerk CERTIFICATE HOLDER NAMED To THE LEFT, BUT FAILURE TO DO SO PO Box 4748 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON Clearwater FL 33758-4748 THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ?} ?QACORD 25 (2001/08) 0AUUKU (;UKPVKAI IUn Ikidd U I T V? J I 1 V 1 "J A "E,V 1 Vl 4 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE (OPTIONAL) Name of Additional Insured Person(s) Or Organizations (As required by written contract/agreement per Paragraph A. below.) Location(s) of Covered Operations (As per the written contract/agreement, provided the location is within the "coverage territory" of this Coverage Part.) (Coverage under this endorsement is not affected by an entry or lack of entry in the Schedule above.) A. Section 11 - Who Is An Insured is amended to include as an additional insured any person(s) or organization (s), including any person or organization shown in the Schedule above, whom you are required to add as an additional insured on this Coverage Part under a written contract or written agreement, provided: a. The written contract or written agreement was executed prior to: 1. The "bodily injury" or "property damage"; or 2. The offense that caused the "personal and advertising injury" for which the additional insured seeks covera9e under this Coverage Part;_and b. The written contract or written agreement pertains to our ongoing operations or "your work" for the additional insured(s). B. The insurance provided to the additional insured is limited as follows: 1. The person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf in the performance of your ongoing operations for the additional insured(s) or c. "Your work" that is included in the "products-completed operations hazard" and performed. for the additional insured, but only if this Coverage Part provides such coverage, and only if the written contract or written agreement requires you to provide the additional insured such coverage. 2. However, we will not provide the additional insured any broader coverage or any higher limit of insurance than the least of those: a. Required by the written contract or written agreement; b. Described in B.I. above; or c. Afforded to you under this policy. http://formnet-ei.ena.com/glhtm/cna7788.htm 1/8/2010 POLICY NUMBER: 0 2 0 6 6 7 2 8 2 2 9 CG 24 04 10 93 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION WITH WHOM YOU AGREE IN WRITING TO WAIVE YOUR RIGHT TO - _--- - - -- - ...: -- - - -- - - -- -- - - RECOVER P.GAINST THEM. YOU MUST AGREE TO THIS WAIVER PRIOR TO THE DATE OF LOSS. (tf no entry appears above, information required to comp applicable to this endorsement-) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV -- COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above fete this endorsement will be shown in the Declarations as because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard." This waiver applies only to the person or organization shown in the Schedule above. CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992 ACORD CERTIFICATE OF LIABILITY INSURANCE /DA7EM , 0110 12/288 2 20 0 PRODUCER Phone: 727-461-6044 Fax: 727-442-7695 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Brown & Brown Insurance - Clearwater ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P O Box 2456 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR . . i ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Su te 660 Clearwater FL 33757-2456 W INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:National Fire In- of Hartford 0478 u King Engineering Assoc., Inc. i l INSURERB:Trans ortation In ranee Co. ----- 0494 4921 Memor a Hwy Ste 300 Tampa FL 33634 wsuRERC:Valle Forge In, prance Com an 0508 •_,_ 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. INSR DD' INSURANCE POLICYNUMBER POLICY EFFECTIVE DATE MM Db POLICY EXPIRATION LIMITS A X GENERAL LIABILITY 02066728229 1/1/2011 11/1/2012 EACHOCCURRENCE $ 1 000 000 . X COMMERCIAL GENERAL LIABILIT.Y_ .. _ DAMAGE TO RENTED PREMISES Ea occurence $500,000 CLAIMS MADE E OCCUR MED EXP (Anyone person) $5, 000 X XCU InCludPd PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE 0 0 0 0 0 0 $ 2 -c_. GEN'LAGGREGATE LIMITAPPLIES PER; PRODUCTS -COMP/OPAGG $ 2-, 000, 000 POLICYFX7 JFPI. LOC A X AUT OMOBILE LIABILITY 02066728232 1/12011 1/1/2012 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1, 000, 000 ALL OWNED AUTOS - BODILY INJURY SCHEDULEDAU70S RECEIV D (Per Person) $ X HIREDAUTOS F BODILY INJURY X NON-OWNED AUTOS (Per accident) $ DEC 2 9 2 10 PROPERTY DAMAGE $ _ (Per accident) GARAGE LIABILITY I\.. AUTO ONLY - EAACCIDENT $ ANY AUTO ISLAWE Ski DEPT EAACC- pTHERTHAN $ AUTO ONLY: AGG $ B EXCESS/UMBRELLALIABILITY - C2066728246 1/12011 1/1/2012 EACH OCCURRENCE $ 5 000 000 1 CLAIMS MADE X OCCUR F AGGREGATE $5,000,000 P ? DEDUCTIBLE X RETENTION $ $ C WORKERSCOMPENSATIONAND ' .: WC163672015 1/1/2011 1/1/2012 CSTATU- O7H- X EMPLOYERS LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT _L1 000 000 OFFICERIMEMBEREXCLUDED? E.L. DISEASE - PA EMPLOYEE $ 1 0Q0 000 If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ 0 0 0, 0 0 0 OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS Certificate Holder is additional insured per the terms of the liability policy with respect to Bodily Injury or Property Damage arising from the work performed by the named insured per form 614033113 01109 (attached). Additional Insured status also applies to Auto Liability. Waiver of Subrogation for General Liability is included in blanket form. * 10 Day Notice for Non Payment of Premium overage is primary & Nan Contributory to any policies held by the certificate holder as required by written contract. CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: City Clerk PO 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 30 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 T. AUUKU ZO (LUUI/Utf) ©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). ----- 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 (2001108) 'lJ 1TV??1JJ V1VJ R THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. BLANKET ADDITIONAL INSURED -- OWNERS, LESSEES OR CONTRACTORS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE (OPTIONAL) Name of Additional Insured Person(s) Or Organizations (As required by written contract/agreement per Paragraph A. below.) Covered (As per the written contract/agreement, provided the location is within the "coverage territory" of this Coverage Part.) (Coverage under this endorsement is not affected by an entry or lack of entry in the Schedule above.) A. Section II - Who Is An Insured is amended to include as an additional insured any person(s) or organization (s), including any person or organization shown in the Schedule above, whom you are required to add as an additional insured on this Coverage Part under a written contract or written agreement, provided: a. The written contract or written agreement was executed prior to: 1. The "bodily injury" or "property damage"; or 2. The offense that caused the "personal and advertising injury" _=for which the additional-insured-seeks coverage,under this -Coverage Part; and-,,- b. The written contract or written agreement pertains to your ongoing operations or "your work" for the additional insured(s). B. The insurance provided to the additional insured is limited as follows: 1. The person or organization is an additional insured only with respect to liability for "bodily injury," "property damage," or "personal and advertising injury" caused in whole or in part by: a. Your acts or omissions; or b. The acts or omissions of those acting on your behalf in the performance of your ongoing operations for the additional insured(s) or c. "Your work" that is included in the "products-completed operations hazard" and performed for the additional insured, but only if this Coverage Part provides such coverage, and only if the written contract or written agreement requires you to provide the additional insured such coverage. 2. However, we will not provide the additional insured any broader coverage or any higher limit of insurance than the least of those: a. Required by the written contract or written agreement; b. Described in B.I. above; or c. Afforded to you under this policy. http://formnet-ci.cna.com/glhtm/cna7788.htm 1/8/2010 kiI + a.) 115 v1 V7 rttgct/ vi iw_ 3. This insurance is excess ofbll other insurance available'to the additional insured, whether primary, excess, contingent or on any other basis, unless the written contract or agreement requires this insurance to be primary. In that event, this insurance will be primary relative to insurance which covers the additional insured as a named insured. We will not require contribution from such insurance if the written contract or written agreement also requires that this insurance be non-contributory. But with respect to all other insurance under which the additional insured qualifies as an insured or additional insured, this insurance will be excess. 4. The insurance provided to the additional insured terminates when your operations for the additional insured are complete. But if the written contract or written agreement specifies a date until which this insurance must apply, then this insurance terminates: a. On the date specified in the written contract or written agreement; or b. When this policy expires or is cancelled, whichever occurs first. C. With respect to the insurance afforded to the additional insured, the following additional exclusions apply. This insurance does not apply to: =- 1. "-Bodily injury,"-"pro.perty-damage,-"--or-"personal ..and advertising-injury.-"-ar-isi.ng out-of-the-rendering .of, or the failure to render, any professional architectural, engineering, or surveying services, including: a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and b. Supervisory, inspection, architectural or engineering activities, 2. "Bodily injury," "property damage," or "personal and advertising injury" arising out of any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this Coverage Part. D. SECTION IV- COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: 1. The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following additional conditions applicable to the additional insured: An additional insured under this endorsement will as soon as practicable: (1) Give us written notice of an "occurrence" or an offense which may result in a claim or "suit" under this insurance, and of any claim or "suit" that does result; (2) Tender the defense and indemnity of any claim or "suit" to any other insurer or self insurer whose policy or program applies to a loss we cover under this Coverage Part; (3) Except as provided in Paragraph B.3 of this endorsement, agree to make available any other insurance the additional insured has for a loss we cover under this Coverage Part; and (4) Send us copies of all legal papers received, and otherwise cooperate with us in the investigation, defense, or settlement of the claim or "suit." We have no duty to defend or indemnify an additional insured under this endorsement until we receive from the additional insured written notice of a claim or "suit." 2. With respect only to the insurance provided by this endorsement, the first sentence of Paragraph 4.a, of the Other Insurance Condition is deleted and replaced with the following: 4. Other Insurance a. Primary Insurance This insurance is primary and non-contributory except when rendered excess by this endorsement, or when Paragraph b. below applies. E. The provisions of the written contract or written agreement do not in any way broaden or amend this Coverage Part. http://foxmnet-ci.cna.com/glhtm/ena7788.htm 1/8/2010 POLICYNUMBER: 02066728229 CG 24041093 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION WITH WHOM YOU AGREE IN WRITING TO WAIVE YOUR RIGHT TO REOQVER AGAINST THEM. ,. YOU MUST AGREE TO THIS WAIVER PRIOR TO THE DATE OF LOSS. (If no entry appears above, information required to comp applicable to this endorsement.) The TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US Condition (Section IV -COMMERCIAL GENERAL LIABILITY CONDITIONS) is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above late this endorsement will be shown in the Declarations as because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products-completed operations hazard." This waiver applies only to the person or organization shown in the Schedule above. A s "s CG 24 0410 93 Copyright, Insurance Services Office, Inc., 1992 PATE (MMIDDIYYYY) ACORD,M CERTIFICATE OF LIABILITY INSURANCE 12/27/2010 PRODUCER phone: 727-461-6044 Fax: 727-442-7695 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Brown & Brown Insurance - Clearwater HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR O Box 2456 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P . . Suite 660 Clearwater FL 33757-2456 INSURED King Engineering Assoc., Inc. 4921 Memorial Hwy Ste 300 Tampa FL 33634 A INSURERS AFFORDING COVERAGE INSURERANatlOX131 Flre -1-n-8--( INSURER B: Transrt at loll Insl wsURERc,3a1je_y, Four e?nsur INSURERD: _ ..? INSURER E: ?r ter... -.. POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE ITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DES( S, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE B1 ADD'L POLICY NUMBER PDOLICYMMFEGTIVE PpLICY EXPIRATION SR 1 1 1/1/2012 GENERAL LIABILITY C2066728229 /1/2001 X COMMERCIAL CLAIMS MADE GENERAL [X] OCCUR GENI AGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC AUTOMOBILE LIABILITY ?C2066728232 ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS X HIREDAUTOS X NON-OWNEDAUTOS GARAGE LIABILITY 6.F.a.>7vir LEXCESSIUMBRELLA LIABILITY C2066728246 7 GLAIMS MADE liVC`65S72 15 B LIABILITY G2 0 6 6 7 2 8 2 4 6 $ O 1NORKERS-CDMPENSATtONAND--- "". 1 EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? Ifves, describe under OTHER 1/1/2011 1/1/2012 A.dEI'VED x 9 2010 R. & OR D5 NE SRV CS DEPT 1/1/2011 y-172-1- 1/1/2012 /-1 /=-2- NAIC # ford 0478 R THE POLICY PERIOD INDICATED. WITH RESPECT TO WHICH THIS RIBED HEREIN IS SUBJECT TO ALL THE EN REDUCED BY PAID CLAIMS. LIMITS EACH OCCURRENCE $ 1 ()00, 000 w O 0 PREMISES (Ea occurence $506 MED EXP (Any one person) $ 5 0 O O PERSONAL BADV INJURY $ 1 0 000 O 0 GENERALAGGREGATE $ 2?O O 0-0 Q 0 PRODUCTS-COMP/ OPAGG $ 2 O O Q, N O O COMBINED SINGLE LIMIT 0 0 0, 0 0 0 $ 1 (Ea accident) , BODILY INJURY $ (Par person) BODILY INJURY $ (Per accident) Y DAMAGE $ nt) Y-EA ACCIDENT $ EAACC * $ AN Y: AGG $ CURRENCE $ 5 000 000 AGGREGATE $ 5 O O 0 0 O $ $ 111- _T-AT E.L. EACH ACCIDENT $ 1 0O 000 E.L.DISEASE-EAEMPLOYEE$ 1 000• 000 E.L. DISEASE - POLICY LIMIT ?$ 1 O 0 O DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS 10 Day Notice for Non Payment of Premium :overage is primary & Non Contributory to any policies held by the certificate holder as required by written contract. City of Clearwater Attn: City Clerk PO 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 30 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) pACORDCUKF'UKAIIUM IVOO 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 (2001/08)