PUMP STATION 41 REHABILITATION - 07-0009-UT - CERTIFICATE OF LIABILITY INSURANCE7 0 CERTIFICATE OF LIABILITY INSURANCE 0DATE 3/22
201YYY)
03/22
2011
/
/
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(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 endorsements .
PRODUCER 1--813-229-8021 Diana Defreouw
X. E. Wilson Co., Inc. PHONE 813-229-8021 FOX
No. Exti: A/C No
300 W. Platt St. App L ddefreeuw@mewilson.com
Ste 200
T
6
FL 336 PRODUCER 00002005
CUSTOMERIDO:
ampa,
0
INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: WESTFIELD INS CO 24112
TLC Diversified, Inc. INSURER B: FCCI INS CO 10178
2719 17th Street East INSURER C:
INSURER D:
Palmetto, FL 34221
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 20213307 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.
INSR
LTR TYPE OF INSURANCE AODLSUBR
INSR POLICY NUMBER (MM/DDfYYYY) EFF POLICY EXP
MMIDD YY
LIMITS
A GENERAL LIABILITY TRA3972460 04/01/1 04/01/12 Ea, HOCCURRENCE $ 1,000,000
MME RCIAL GENERAL LIABILITY
c
o
D AU, RENTED
REM SES Eoccu ence
P
$ 150 , 000
4 CLAIMS-MADE ? OCCUR
] MED EXP (Any one person) $ 10, 000
x ntractual Liability
c
. PERSONAL & ADV INJURY $ 1,000,000
X $500 Prop Dmg bed GENERAL AGGREGATE $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: ., PRODUCTS -COMP/OP AGG s 2,000,000
POLICY X PRO- X LOC $
A AUT OMOBILE LIABILITY TRA397246 -
I 04/01/13 04/01/12 COMBINED SINGLE LIMIT $ 1,000,000
(Ea accident)
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS
PROPERTY DAMAGE
X
HIRED AUTOS
' \t
(Per accident) $
X NON-OWNED AUTOS C $
A X UMBRELLA LIAB X OCCUR TRA3972460 04/01/1 04/01/12 EACH OCCURRENCE $ 5,000,000
EXCESS LIAe CLAIMS-MADE AGGREGATE $ 5,000,000
DEDUCTIBLE $
X RETENTION $ 0 $
B WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY NC09ASIS61 04/01/1 04/01/12 X WCSTATU- OTH-
DRY
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
?
N
/a E.L. EACH ACCIDENT $ 500,000
.
(Mandatory 1. NH) EXCLUDED? .. -
` E.L. DISEASE EA EMPLOYE $ 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L, DISEASE - POLICY LIMIT 500,000
$
A Installation Floater TR10972460 U4,101/13 04/01/17 Any no ite:
Transit & Storage: Included
Deductible: 1,000
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more apace Is required)
Additional Insured: TBE Group, Inc., 380 Park Place Boulevard, Suite 300, Clearwater, Florida 33759
Pump Station 441 Rehabilitation Project
Executive Officers Joanne Lamberson and Thurston Lamberson are excluded from Workers' Compensation coverage.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater
Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Alice R. Eckman
P
O
Box 4748
.
. AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748
USA
l
r7
KDO01 ®1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
20213307
N. E. Wilson Co., Inc.
300 W. Platt St.
Ste 200
Tampa, FL 33606
USA
City of Clearwater
Attn: Alice R. Sckman
P.O. Box 4748
Clearwater, FL 33758-4748
USA 4:36:360
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