CERTIFICATE OF INSURANCE (242)
JRD CERTIFICATE OF LIABILITY INSURANCE 1 DATE (MMlDDIVYVY)
TM 09/16/2004
~R (865)691-4847 FAX (865)694-4847 THIS CERTIACATE IS ISSUED AS A MATTER OF INFORMATION
Insurance Services, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
~OO Winston Road, Suite 100 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P,O. Box 10328
Knoxville, TN 37939-0328 INSURERS AFFORDING COVERAGE NAIC#
INSURED Phi 11 ips " Jordan, Inc., et al INStRR A American Contractors Insurance C RRG A VII
Attention: Steve Thompson INSURER B ACIG Insurance Company A VII
6621 Wilbanks Rd INSURER C Westchester Fire Insurance Compal y/WSRB A X
Knoxville, TN 37912 INSURER D
INSURER E'
, Time. 6.01 PM To: William B. Horne II g 9,17275624052#",69987 TIS line 2
Page: 002
COVERAG~S
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANDING
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.
I~~ DD'L TYPE DF INSURANCE POLICY NUMBER POLICY EFFECTIVE Pg~fl EXPIRATION LIMITS
NS'Ri'
GENERAL LIABILITY GD04045029 06/01/2004 06/01/2005 EACH OCCURRENCE $ 2,000,000
i---
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
l CLAIMS MADE [KJ OCCUR MED EX? (Any one person) $ 5,00
A PERSONAL & ADV INJURY $ 2,000,000
GE~RAL AGGREGATE $ 4,000,000
GEN'L A(.GREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 4,000,000
h POLICY [Xl 'l2T n LOC
AUTOMOBILE LIABILITY AR04045016 06/01/2004 06/01/2005 COMBIIIED SINGLE LIMIT
- $
X ANY ALlTO (Ea aCCident) 2,000,000
-
ALL OWNED AUTOS BODIL Y INJURY
- $
SCHECUED AUTOS (Par person)
A -
X HIRED AUTOS BOOIL Y INJURY
X $
NON-OWNED AUTOS (Per accident)
-
I-- PROPERTY ().IlMO.GE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY ALITO OTHER THAN EA ACC $
AUTO ONI.. Y. AGG $
EXCES~MBRELLALIABLITY CUW7810410 06/01/2004 06/01/2005 EACH OCCURRENCE $ 10, 000, OOC
~ OCCUR, D CLAIMS MADE AGGREGATE $ 10,000, DOC
C $
~ DEDUCTIBLE $
X RETENTION $ 10,000 $
WORKERS COMPENSATION AND W004045048 06/01/2004 06/01/2005 X I ~N:1I'4;.1 IO~
EMPLOYERS' LIABILITY WR04045014 500,000
B .<\NY PROPRIETORIPARTNERiEXECUTIVE EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $ 500,OOll
If yes, describe under 500,000
SPEO,'Il PROVISIONS bel"", EL DISEASE - POLICY LIMIT $
DTHER
~ESCRlPTlON OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPEC1AL PROVlSIDNS
roject: Disaster Debris Removal, Reduction, and Disposal
Whe Certificate Holder is Additional Insured regarding General liability and Automobile liability with
~egard to work perfonmed by the Insured on this project.
I"U::D -, , A .,_..
~{;f~ SHOULD AN'( OF THE ABOVE DESCRIBED POUClES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
i , CkVt- ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of Clearwater
Attention: William B. Horne II BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
P. O. Box 4748 OF AN'( KIND UPON THE INSURER. ITS AGENTS OR REPRESENTATIVES.
Clearwater, Fl 33758-4748 AUTHORIZED REPRESENTATIVE (Llk-
Construction Div./CATWAR
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mar.nRn r.nRPORATION 1988