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COMPRESSED NATURAL GAS FILLING STATION - 10-0043-GA - CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 12/15/2011 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Millennium Insurance & Investments Corp d/b/a MiiCorp HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3440 Hollywood Blvd. Suite 415 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hollywood, FL 33021 Phone: (954) 983-4252 Fax: (954) 212-2255 INSURERS AFFORDING COVERAGE NAIC # INSURED Burlington Insurance Company23620 INSURER A: Wise Gas Inc. Etal INSURER B: 1058 Bluewood Terrace INSURER C: Weston, FL 33327 INSURER D: INSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADD'L INSRPOLICY EFFECTIVEPOLICY EXPIRATION INSRD TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD/YY) DATE (MM/DD/YY) LIMITS LTR 1,000,000 AHGL002951212/15/201112/15/2012 GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY 50,000 $ PREMISES (Ea occurence) CLAIMS MADE OCCUR 1,000 MED EXP (Any one person) $ 1,000,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ *Hired &Non Owned Auto 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Ded BI,PD,AI & ALAE5,000 Per Occ POLICY LOC PROJECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION $ $ WC STATU-OTH- Refer to separate WORKERS COMPENSATION AND TORY LIMITSER EMPLOYERS' LIABILITY Certificate attached E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ If yes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS RE: Compressed Natural Gas Filling Station #10-0043-GA Blanket Additional Insured, Blanket Waiver of Subrogation & Blanket Primary Non Contributory applies to the General liability policy only when required by written contract. Per attached Endt’s (CG 20 10 07 04, CG 20 37 07 04, CG 24 04 05 09 & IFG-G-0094 12 07) **30 Days Advance Notice of Cancellation EXCEPT for Non-Payment of Premium 10 Days CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION ADDITIONAL INSURED: ** DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN City of Clearwater NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Engineering/Construction Division IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 100 So. Myrtle Ave. REPRESENTATIVES. 2nd Floor- Suite 220 AUTHORIZED REPRESENTATIVE Clearwater, FL 33756 Gloria J. Bravo, CIC ACORD 25 (2001/08) © ACORD CORPORATION 1988 CERTIFICATE OF INSURANCE RE :0196-18440Producer :Gloria Josefina Bravo ISSUED TO :City of Clearwater Engineering/ConstructionCompany :Millennium Ins.& Inv. Corp. Division 100 So. Myrtle Ave.Address :3440 Hollywood Blvd., Suite 2nd Floor- Suite 220415 Clearwater, FL 33756Hollywood, FL 33021 Phone :(954) 983-4252 This is to certify that Wise Gas Inc, 1058 Bluewood Ter Weston, FL 33327-2056, being subject to the provisions of the Florida Workers' Compensation Law, has secured the payment of any workers' compensation benefits due by insuring their risk with the Bridgefield Casualty Insurance Company. POLICY NUMBER:0196-18440Statutory Limits -- State of Florida, Georgia Employers Liability EFFECTIVE DATE:January 04, 20111,000,000 (Each Accident) 1,000,000 (Disease--Each Employee) EXPIRATION DATE:January 04, 20121,000,000 (Disease--Policy Limit) Job: Compressed Natural Gas Filling Station #10-0043-GA This certificate is not a policy and of itself does not afford any insurance. Nothing contained in this certificate shall be construed as amending, extending, or altering coverage not afforded by the policy shown above or affording insurance to any insured not named above. The policy of insurance listed above has been issued to the named insured for the policy period indicated. Notwithstanding any requirement, term or condition of any contract or other document to which this certificate may pertain, the insurance made available by the described policy in this certificate is subject to only the terms, exclusions and conditions of such policy. Paid claims may have reduced the shown limits. If the policy described above is cancelled before the expiration date indicated, the issuing company will endeavor to mail 30 days' written notice to the certificate holder named above, although if cancellation is for nonpayment of premium, then the issuing company will endeavor to mail 30 days' written notice to the certificate holder. In any event, the issuing company, its agents, and representatives accept no obligation or liability of any kind for failure to mail such notice. Date: December 15, 2011 CERTIFICATE OF INSURANCE RE :0196-18440Producer :Gloria Josefina Bravo ISSUED TO :City of Clearwater Engineering/ConstructionCompany :Millennium Ins.& Inv. Corp. Division 100 So. Myrtle Ave.Address :3440 Hollywood Blvd., Suite 2nd Floor- Suite 220415 Clearwater, FL 33756Hollywood, FL 33021 Phone :(954) 983-4252 This is to certify that Wise Gas Inc, 1058 Bluewood Ter Weston, FL 33327-2056, being subject to the provisions of the Florida Workers' Compensation Law, has secured the payment of any workers' compensation benefits due by insuring their risk with the Bridgefield Casualty Insurance Company. POLICY NUMBER:0196-18440Statutory Limits -- State of Florida, Georgia Employers Liability EFFECTIVE DATE:January 04, 20121,000,000 (Each Accident) 1,000,000 (Disease--Each Employee) EXPIRATION DATE:January 04, 20131,000,000 (Disease--Policy Limit) Job: Compressed Natural Gas Filling Station #10-0043-GA This certificate is not a policy and of itself does not afford any insurance. Nothing contained in this certificate shall be construed as amending, extending, or altering coverage not afforded by the policy shown above or affording insurance to any insured not named above. The policy of insurance listed above has been issued to the named insured for the policy period indicated. Notwithstanding any requirement, term or condition of any contract or other document to which this certificate may pertain, the insurance made available by the described policy in this certificate is subject to only the terms, exclusions and conditions of such policy. Paid claims may have reduced the shown limits. If the policy described above is cancelled before the expiration date indicated, the issuing company will endeavor to mail 30 days' written notice to the certificate holder named above, although if cancellation is for nonpayment of premium, then the issuing company will endeavor to mail 30 days' written notice to the certificate holder. In any event, the issuing company, its agents, and representatives accept no obligation or liability of any kind for failure to mail such notice. Date: December 15, 2011 IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2001/08)