CERTIFICATE OF LIABILITY INSURANCE (8)A�� � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
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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 NAME:
BY'OWri & BY'OWIl Insurance - Clearwater PHONE FAX
P.O. Box 2456 A/C No Ext: - - AIC No: - -
E-MAIL
SU1t2 660 ADDRESS:
Clearwater FL 33757-2456 PRODUCER^y
INSURED
King Engineering Assoc., Inc.
4921 Memorial Hwy Ste 300
Tampa FL 33634
INSURER A : Ndt
iNSUReR e : Tra:
INSURER C : Val
INSURER D :
INSURER E :
INSURER F :
INSURER(S) AFFORDING COVERAGE
ional Fire Ins of Hartford
Insurance
NAIC #
20478
2050
COVERAGES CERTIFICATE NUMBER:1771960703 REV1510N 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 7ypE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS
LTR IN R WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A GENERALLIABILITY C2066728229 1/1/2012 1/1/2013 EACH OCCl1RRENCE $1,000,000
DAMAGE TO RENTED
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $500, 000
CLAIMS-MADE � OCCUR MED EXP (Any one person) $5, 000
X XCU Included PERSONAL&ADV INJURY $1, 000, 000
GENERALAGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2. 000 , 000
POLICY X PRO- LOC $
A AUTOMOBILELIABILITY C2066728232 1/1/2012 1/1/2013 COMBINEDSINGLELIMIT $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 (Per accident)
X NON-OWNED AUTOS $
$
g UMBRELLALIAB X OCCUR C2066728246 1/1/2012 1/1/2013 EACHOCCURRENCE $5,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $5, 000, 000
DEDUCTIBLE S
X RETENTION $0 $
� WORKERSCOMPENSATION WC163672015 �1/1/2012 1/1/2013 X WCSTATU- OTH-
AND EMPLOYERS' LIABILITY Y� N TORY LIMIT ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1, 000, 000
OFFICER/MEMBER EXCLUDED? � N � A
(Mandatory in NH) E.L. DISEASE -EA EMPLOYE $1, 000, 000
If yes, describe under
DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICYLIMIT $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Certificate Holder is additional insured per the terms of the liability policy with respect to Bodily
Injury or Property Damage arising from the work performed by the named insured per form G140331B O1/09
(attached). Additional Insured status also applies to Auto Liability. Waiver of Subrogation for
See Attached...
CERTIFICATE HOLDER ��, �� , CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
r BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
City of Clearwater
DEI,+ � �� �� �1 IN ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: City Clerk � `�
PO BOX 4 7 4 8 �1 ��pd �. f:� .. �". i if�� t UTHORIZED REPRESENTATIVE
Clearwater FL 33758-474���� � -. � -�. ;r,-
v..�. y 4'e � � � � � �.� � "�%7�1�?,�.. + , /�Ln��
I
U 79$8-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC #:
AC+C7�R[..�7►� ADDITIONAL REMARKS SCHEDULE Pa9e 1 af 1
��
ACaENCY NAMEDINSURED
Brown & Brown Insurance - Clearwater King Engineering Assoc., Inc.
4921 Memorial Hwy Ste 300
POLICYNUMBER Tampa FL 33634
CARRIER
NAIC CODE
EFFECTIVE DATE:
ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
tJt�ussi� u�uy
� �
Polzcy #C20b6728229 rage t orz
THIS ENDORSEMENT CHANGES THE P�i.ICY. PLEASE READ IT CAREFULLY.
BLANKET ADDtT1�NAL [NSURED - �WVNERS, LESSEES 4R
con�s�c-roas
This endorsement mociifies insurance provided under ihe fofiowing:
COMMERCiAL GENERAL LIASfLITY COVERAGE PART
SCHEDULE {QPTlQNAL)
Name of Additional tnsured Person(s)
Or Oroanizatioris
{As required by written contract/agreement per Paragraph A heivw.)
Locatian(sy of Coverecf Operati�ns
(As per the written contrac�/agreement, pravided the location is within the "coverage territory" of this Coverage
Pa�. )
(Coverage under
�ot affected by an entry or lack af entry in the Schedule above.)
A, Section li - Who I� An Insured is amended to incEude as an addif€onal insured any person(s} or organization
(s), incfuding any person or organization shown in the Schedufe abave, whom you are required to add as an
additianal insured on this Coverage Part under a written coniract or written agreement, provided:
a. The written c�ntract or wri#ten agreement was executed prior to:
1. The "bodily injury" or "property damage"; or
2, The offense that caused the "personaf and advertising in}ury"
for which ihe additional insured seeks coverage under this Coverage Part; and
b, The written contrac# or writien agreement pertains to your ongoing operations or "your work' for the
additional insured{s).
B. The insu.rance provided to the additiona! insured is limited as follows:
4. The person or organization is an additional insured only with respect to Eiability for "bodily injury," "property
damage," or "personal and advertising injury" caused in whoke ar in part by:
Your acts or omissions; or
b. The acts or ornissions of those acting on your behalf
in the performance of your ongoing aperations for the additional insured(s) or
c. "Your work" ihat is included in the "products-campleted operations hazard" and performed for the
additional insured, but oniy ii this Coverage Part provides such coverage, and only if the writ#en
contract or written agreement requires you to provide the additional insured such coverage.
2. However, we wil! nai provide the additiona{ insured any broader coverage or any higher limit of insurance
than the least of those;
a. Required by tF�e written contract ar written agreement;
b. Described in B.1, above; ar
c. Afforded to you under this poticy.
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Ci24U331B 0109 Yage l ot Z
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3, This insurance is excess of �!I other msu.rance available'to the additional insured, whether primary,
excess, contingent or on any other basis, unless the written contract or agresment requires this insurance
to be primary. In that event, this insurance will be primary relative to insurance which covers t}ze
additional insured as a named insured. We will not require coniribution from such insurar�ce if the written
contract or written agreement aEsa requires tha# this insurance be non-contributory. But with respect to all
other insurance under which the additionaf insured quaiifiies as an insured or additional insured, tnis
insurance wil! be excess.
4. The insurance provided to the additional insured terminates when your operations for the additional
insured are com�tete. But if the wriiten contract or written agreement specifres a date untii which this
insurance must apply, then this insurance termina#es:
a. On the date specifled in the written confract or written agreement; or
b. When this palicy expires or is cancelled,
whichever occurs first.
C. With respect to the insurance afforded to the additional: insured, the following additiona[ exclusions apply.
This insurance does nat apply to:
1. "Bodily inJury," "property damage," or "personal and advertising injury" arising ouY of the rendering of, or
the failure to render, any professional architeciural, engineering, or surveying services, including:
a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports,
surveys, fietd arders, change orders or drawings and specificatians; and
b. Supervisory, inspection, architecturaf or engineering activities.
2. "Bodily injury," "property damage," or "personal and advertising injury" arising out of any premises or work
for which the additional insured is speci�cafly #isted as an addiiional insured on another endorsement
attached to this Coverage Pa�.
D, SECTION IV — COMMERCIAL GENERAL LtABILITY CONDlTI4NS is arnended as falfows:
9. The puties In The Event of Occurrence, Offense, Claim or Suit conditian is amended to add the
foflowing additionai conditians applicabfe to the additional insured;
An ad�itionai insured under this endorsement wilf as soon as practicable:
(1 � Give us written notice of an 'bccurrence" or an offense which may result in a claim or "suit" under this
insurance, and ot any cEaim or "suit" that does result;
12)
(3)
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7ender the defense and indemniry of any claim or "suit" to any other insurer or selt insurer whose
policy or program applies to a loss we cover under this Coverage Part;
Except as provided in Paragraph 6,3 oi this endorsement, agree to make available any other
insu�ance the additionaf insured has for a loss we cover under this Coverage Part; and
Send us copiss of all legai papers received, and otherwise cooperate with us in the investigation,
d.efense, or settlemeni of the claim or °sui#."
We have �o duty fo defend or indemnify an additional insured under this endorsement until we receive
from the additiona! insured written notice of a claim or "suit."
2. Vl�th respect only to the insurance provided by this endorsemen#, the first sentence of Paragraph 4.a. of
the Other Insurance Conditi�n is deleted and replaced with the foNowing:
4. Other Insurance
a. Primary insurance
This insurance is primary and non-contributory
endorsement, or when Paragraph b. below applies.
E. ihe provisions of ihe written contract or written agreement
Coverage Part.
except when rendered excess by this
do not in any way braaden ar amend t�is
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Po�.iCY NUMBER: C 2 0 b b 7 2 8 2 29 CG 24 04 10 93
TNfS ENDORSEMENT CHANGES THE PC1LlCY. PLEASE READ IT CAREFULLY.
INAIVER UF TRANSFER OF RiGHTS
4F REGOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the #oliowing:
COMMERCIAL GENERAL L(ABiLiTY COVERAGE PART
SCHEDULE
Name oi Ferson nr Organization:
ANY PERSON OR ORCAIVIZATIOI3 WITH WH�M YOU
AGREE TN WRITIIVG TO WAIVE YOUR RIGEi'T TO
RECQVEk2 AGAINST THEM. YOU NlUST AGREE TO
THIS LVATVER PRIOR TO 'I'HE DATE OF LOSS .
(tf no entry appears above, infiormafian required to comp(ete this endorsement will be shawn in #hs Dedarations as
appEicable to this endorsement.)
The TRANSFER OF Fi1GHTS OF RECOVERY AGAINST because of payments we make for injury or damage arising
OTHERS TO US Conditian (Section EV — COMMERGiAL aui of your ongoing operations or "your work" done under a
GENERAL LIABILITY CONdITIONS} is amencied by the contract with that person or organization and inciuded in the
addition of the following: "products-comple#ed apera6ons hazard." Th'ss waiver
We waive any right of recovery we may have against the appfies oniy ta the person or organization shown in the
person or arganization shown in the Schedule above Schedule above.
CG 24 64 90 93 Copyright, Insurance Services Office, Inc., '[892