CERTIFICATE OF LIABILITY INSURANCE (113)A CERTIFICATE OF LIABILITY INSURANCE 005AT 'M"D(YYYY)
12120011
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 endorsements .
PRODUCER CONTACT
NAME`
Marsh USA Inc. PHONE FAX
701 Market Street, Suite 1100 A/C Na :
St. Louis
MO 63101 E-MAIL
, ADDRESS:
Attn: stlouis.oertrequest@marsh.com 212-948.0811 PR
ODUCER
CUSM96 19 1,
800679-STND-GAWUe-11-12 INSURERS AFFORDING COVERAGE NAIC 4
INSURED INSURER A ; Travelers Property Casualty Co. of America 25674
FiberLighl, LLC
11700 Great Oaks Wa
Suite 100
NIA
INSURER B:
N/A
y,
Alpharetta, GA 30022 INSURER C : N/A N/A
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: CHI-002907390.15 REVISION NUMBER: 3
F AUTOMOBILE LIABILITY COM13INED SINGLE LIMIT $
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 ADDL SUBR POLICY NUMBER POLICY EFY PW I OY EY LIMITS
A GENERAL LIABILITY H6306746PI20TIL11 05/0912011 05/09/2012 EACH OCCURRENCE $ 1,000,000
X
COMMERCIAL GENERAL LIABILITY AMAG T ENTED
PREMISES Ea occurrence 1,000,000
$
CLAIMS-MADE 17] OCCUR MED EXP Any one person $ 10,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY PRO X LOC $
(Ea accident)
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED AUTOS BODILY INJURY (Per accident) $
SCHEDULED AUTOS
HIRED AUTOS
13 2011
PROPERTY DAMAGE
(Per accident)
$
NON-OWNED AUTOS $
y?
UMBRELLA LIA9 OCCUR 5LATW c??:v s DEOT E ACH OCCURRENCE $
EXCESS LIAR H CLAIMS-MADF C AGGREGATE $
DEDUCTIBLE $
RETENTION $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY
Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE ?
A E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N/
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
II yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Re: Right of way - Franchise
Subject to all policy terms, conditions and exclusions, the City of Clearwater is included as additional insured on the above General Liability Policy ONLY as required by written contract and as respects to building access
license agreement.
L;EH 1 II-IE;A 1 E HULL)EK t;ANGtLLA I IUN
City of Clearwater
a political subdivision of the
State of Florida
112 S. Osceola Avenue
Clearwater, FL 33756
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Katey E. Jones
®1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
I.. r
0000417 SP 0119 -C01-P00417.1
City of Clearwater
a political subdivision of the
State of Florida
112 S. Osceola Avenue
Clearwater, FL 33756