CERTIFICATE OF LIABILITY INSURANCE (165)OP ID: JI
'4` °R°? CERTIFICATE OF LIABILITY INSURANCE DIYYYY)
DAT
03129
03/29!11
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 policy(ies) 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 :....... ._..... ...
516-745-7500 ......... .., .
, CONTACT
NAME:
The Amerisc Cori l
..... 516-745-7565
Suite 2
777 Zeckendlirf Blvd PHONE ac
.,
Garden City. NY 11530 ADDRESS:
P
CUSTOMER RODUCER
INSURE S AFFORDING COVERAGE NAIC #
INSURED Sam Schwartz Engineering, PLLC INSURER A: Charter Oak Fire Ins Co 25615
611 Broadway, Suite 415 INSURER B :Travelers Indemnity Co America 25666
New York, NY 10012 INSURERC:*Hartford Fire Ins. Co. 19682
INSURERD:Landmark Insurance Co.
INSURER E : National Union Fire Ins. Co. 19445
INSURER F: I
r•_nv?aaAr?E CERTIFICATE NUMBER: REVISION NUMBER:
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.
ILTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM/DDIYYYY MMLDD/YYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00
A X COMMERCIAL GENERAL LIABILITY X 68025SM6519 10!10110 10/10/11
DAMAGE TO RENTEU
P
REMISES Ea occurcence
$ 300,00
CLAIMS-MADE OCCUR MED EXP (Any one person) $ 10,00
X Contractual Llab. PERSONAL & ADV INJURY $ . 1,000,00
GENERAL AGGREGATE $ 2,000,0010
GEN'L AGGREGATE ,LIMIT APPLIES PER' PRODUCTS - COMP/OP AGG` $ 2x000,00
POLICY PRO- X LOC
AUT OMOBILE LIABILITY
COMBINED
SINGLE ) LIMIT
(Ea accident
$ 1,000,00
A ANY AUTO 6805684L860 ?V D10/10 10110111 BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS ?j 1
APR O 1 O?? (PeraOGdenl) $
X NON-OWNED AUTOS $
5 ?f 1 /?
e,FIC AL c . ?`Y MJ` U
$ $
X UMBRELLA LIAB OCCUR IE WLATM SNA EACH OCCURRENCE $ 51000,00
EXCESS LIAR H CLAIMS-MADE
/1
1
/11
/1 AGGREGATE $ 6,000,00
B DEDUCTIBLE C U P3588T749 10/10
0 0
0 $
-'--- - - RC-TEtrTtON. ..-----10000------_._ ....__. ..._... _...-------- -__._.. _, ----. -..._._ ..-- ---._...--- ----...?- ---- °-- -..----___.....-_.--- ---- 3--- ------------
WORKERS COMPENSATION
' WC 5TATU- OTH-
C LIABILITY
AND EMPLOYERS
ANY PROPRIETOR/PARTNER/EXECUTIVE Y
12WECFX1833
10/11110
10/11/11
E.L. EACH ACCIDENT
$ 1,000x00
?
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) N / A
E.L. DISEASE - EA EMPLOYEE
$ 1,000,00
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,00
D
E Professional Llab
Excess Liability LHR726058
BE023678445 05/18/10
10/13/10 05/18/11
10/13/11 Aggregate 2,000,00
Liab Lim 5,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
City of Clearwater is Included as an additional insured per written contract
or agreement.
CERTIFICATE HOLDER CANCELLATION
CITYOFC
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn: City Clerk ACCORDANCE WITH THE POLICY PROVISIONS.
P.O. Box 4748
Clearwater
FL 33758-4748 AUTHORIZED REPRESENTATIVE
, APMER resfdSCenFRP
ACORD 26 (2009/09)
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The ACORD name and logo are registered marks of ACORD