EAST PLANT ANOXIC TANK - 09-0007-UT - CERTIFICATE OF LIABILITY INSURANCEkC40RO? CERTIFICATE OF LIABILITY INSURANCE 03%22%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(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 1-8 3-229-8021 CN0NT Diana Defreeuw
R. E. Wilson CO., Inc., PHONE Fig): M. No.
114"IC. No
300 W. Platt St. A?L ddefreeuw@mewilson.com
Pte 200 PRODUCER 00002005
Tampa rL 33606 CUSTOMER 1091
r INSURER(S) AFFORDING COVERAGE NAIC #
INSURED INSURER A: WESTFIELD INS CO 24112
TLC Diversified, Inc. INSURER e: FCCI INS CO 10178
2719 17th Street East INSURER C:
INSURER D :
Palmetto, FL 34221
INSURER E
COVERAGES
CERTIFICATE NUMBER: 20213315
REVI51UN NUMbt:K:
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 DL SUB- POLICY NUMBER MMPOLICY IDDI EFF PMIDU EXP
JML AMR LIMITS
A GENERAL LIABILITY - TRA3972460 04/01/1 04/01/12 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY P?G Ea occurrence $ 150,000
CLAIMS-MADE FX] OCCUR MED EXP Any one person) $ 10,000
X ContraCtu81 Liability PERSONAL & ADV INJURY $ 1,000,000
X $500 Prop Ding Ded GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
l CT PRO- X LOC
POLICY X rr
1?
$
A AUT OMOBILE LIABILITY TRA3972460 ",f„, a.,'?.. 04/01/1 04/01/12 COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
X ANY AUTO
BODILY INJURY (Per person)
$
ALL OWNED AUTOS
BODILY INJURY (Per accident)
$
SCHEpUL AUTOS \* ( PROPERTY DAMAGE
$
X HIRED AUTOS (Per accident)
X NON-OWNED AUTOS $
$
A X UMBRELLA LIAB X OCCUR TPA3972460
' 04/01/1 04/01/12 EACHOCCURRENCE $ 5,000,000
EXCESS LIAR CLAIMS-MADE r AGGREGATE $ 5,000,000
DEDUCTIBLE - $
X RETENTION $ 0 $
g WORKERS COMPENSATION WC09A61661 04/01/1 04/01/12 X WCSTATU- OTH-
TO,, LMT
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
El. EACH ACCIDENT
$ 500,000
..... ?
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) NIA
E.L. DISEASE - EA EMPLOYE
S 500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT 500 000
$ r
A Ins a a ion Floater TRA39 Tff4TsT U417UI71 4/01/12 Any One i : 1 000,000
,
? Transit & Storage: Included
Deductible: 1,000
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES Attach ACORD 101, Additional Remarks Schedule, K more space Is required)
City of Clearwater as additional insured
East Plant Anoxic Tank (09-0007--UT)
Executive Officers Joanne Lamberson and Thurston Lambersen are excluded from Workers' Compensation coverage.
ACbTICrf?ATC UPI n=n f AN1*.PI 1 ATInN
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.O. Sox 4748
AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748 C
"
USA ! (?
KDO01 WO 73615-LUUN AIrUKU L UKrVKAI IUIY. All rlgnis reserves.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
20213315
M. E. Wilson Co., Inc.
300 N. Platt St.
Ste 200
Tampa, FL 33606
USA
City of Clearwater
Attn: Alice R. Eckman
P.O. Box 4748
Clearwater, FL 33758-474$
USA 4:39:360
IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII
... rS
BIX BPO
TO
h
This document was brought to you by CertificatesNow.
--Ff-yon_r -wegarding--the-content -of--this -document lease-centaet
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 customercare@confirmnet.com, or visit our website at
www.confirmnet.com
cc:
The data included in this notice and in the attached document is confidential to Ebix BPQ
and the party responsible for bringing you this Information.
i:2
Certificate Delivery by CertiflcatssNow - www.CanfirmNet.com - 877.869.8600