MARSHALL STREET AND EAST APCF CHLORINE GAS AND SULFER DIOXIDE GAS CONVERSION PROJECT - 07-0021-UT - CERTIFICATE OF LIABILITY INSURANCELip CERTIFICATE OF LIABILITY INSURANCE 0322/20111 "'
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.pn endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER 1-813-229-8021 CONTACT Diana Defreeuw
NAME:
M. E. Wilson Co., Inc. PHONE ,813-229-8021 FAX
ac Nc
300 W. Platt St. ADDDRESS: ddefreeuw@mewilson.com
Ste 200 PRODUCER 00002005
CUSTOMER ID III:
Tampa, FL 33606
INSURERS AFFORDING COVERAGE NAIC 9
INSURED INSURER A: WESTFIELD INS CO 24112
TLC Diversified, Inc. INSURER B: FOCI INS CO 10178
2719 17th Street East INSURER C:
INSURER D:
Palmetto, FL 34221
INSURER E :
INSURER F ;
COVERAGES CERTIFICATE NUMBER: 20213369 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.
INSSR TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP
POLICY NUMBER (MMIDDNYYY) (MMIDOIYYYY) LIMITS
A GENERAL LIABILITY TRA3972460 04/01/1 04/01/12 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY REPREMISES Ea occurrence) $ 150,000
CLAIMS-MADE Fx] OCCUR MED EXP (Any one person) $ 10,000
X COntraCtLlal Liability PERSONAL & ADV INJURY $ 1,000,000
X $500 Prop Dmg Ded GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000
POLICY X PRO- X LOC $
A AUT OMOBILE LIABILITY TRA3972460 RM.a 04'/01/13 04/01/12 COMBINED SINGLE LIMIT
E
id
t $ 1,000,000
a acc
en
)
(
X ANY AUTO ^
BODILY INJURY (Per person)
$
OWNED AUTOS
ALL C
4 \
4O \?
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS 2 1-' PROPERTY DAMAGE
X HIREDAUTOS M.AR (Per accident) $
-`
X NON-OWNED AUTOS $
$
A X UMBRELLALIAB X OCCUR TRA3972460 (_. 04/01/1 04/01/12 EACH OCCURRENCE $ 5,000,000
EXCESS LIAB CLAIMS-MADE - AGGREGATE $ 5,000,000
pEDUCTIBLE $
X RETENTION 0 $
B WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY NC09AS1661 04/01/1 04/01/12 X WCSTATU- OTH-
I TORY LIMITS
YIN
ANY PROPRIETOR/PARTNER/EXECUTIVE
?
NIA E.L. EACH ACCIDENT $ 500,000
OFEICERIMEMBER EXCLUDED?
(Mandatory In NH) . . _.
E.L. DISEASE - EA EMPLOYE
$ 5001000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT 500,000
$
A Installation Floater TRA3972 60 U4/U:L/:L3 04101/17 Any One Site;
Transit & Storage: Included
Deductible: 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD IR, AddRlonal Remarks Schedule, If more apace Is required)
City of Clearwater as additional insured
Marshall Street 6 East APCF Chlorine Gas 6 Sulfur Dioxide Gas Conversion Project (07-0021-UT)
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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Alice R. Eckman
P
4748
B
O
.
ox
. AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748 ?; F
LISA
/x CA y ^ '
0
PM001 m 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
20213369
M. E. Wilson Co., Inc. ?n ! Now 4,
300 W. Platt 8t. , w
te 200 M
Tampa, FL 33606
S`0
USA MAR 2 g 2011 BIX Bgi*j
City of Clearwater °sr1, :•, r'R
Attn: Alice R. Eckman
P.Q. Box 4748
Clearwater, FL 33758-4748
USA 4:40:360
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
This document was brought to you by CertificatesNow.
___If.-you-hem, pe i-ens--regarding-lase-content-of-this-.document,-please:'contact-
the Producer/Agent listed on the certificate of insurance or the Insured listed
on the notice of cancellation/reinstatement.
To find out how you can send and receive all of your certificates of insurance
either by email, high speed fax or standard mail,
email cuettomercare@confirmnet.com, or visit our website at
www.confi=net.com
Co.
The data included in this notice and in the attached document is confidential to Ebix BPO
and the party responsible for bringing you this information.
1:2
Certificate Delivery by CertificatesNow - www.ConfirrnNet.corn - 877.668.8600