CLEVELAND STREET PHASE II - 08-0055-EN - CERTIFICATE OF LIABILITY INSURANCE (2)'�` °R°� CERTIFICATE OF LIABILITY INSURANCE 4/4/2012�Y)
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 CONTACT D2bb12 Baile
NAME: y
Stahl & Associates Insurance, Inc. PHONE .(727) 391-9791 p/C No: �72��393-5623
110 Carillon Parkway A��R�ESS:debbie.bailey@stahlinsurance.com
St. Petersburg
INSURED
MTM Contractors Inc.
6550 53rd Street N
Pinellas Park
COVERAGES
INSURER(S) AFFORDING COVERAGE NAIC #
FL 33716 iNSUReRa:Phoenix Insurance Com an 25623
iNSUReRe:Travelers Pro ert Casualt Co 25674
iNSUReRC:Brid efield Em lo ers Ins Co 10701
INSURER D :
FL 33781 � iNSi
CERTIFICATE NUMBER:CL1231514247
':7=V/6�[�7���t�1��d:i=l:ii
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 TypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
GENERAL LIABtLITY EACH OCCURRENCE $ 1� OOO � OOO
DAMAGETORENTED 3OO OOO
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ �
�i CLAIMS-MADE � OCCUR 0319X5523 $�20/2011 8/20/2012 MED EXP (Any one person) $ 1� � 0��
PERSONAL & ADV INJURY $ 1� OOO � OOO
GENERAL AGGREGATE $ Z� OOO � OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Z� OOO � OOO
POLICY X PR� LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Eaaccident $ 1 0�� 0��
A X ANY AUTO BODILY INJURY (Per person) $
ALLOWNED SCHEDULED 810836G6071 8/20/2011 8/20/2012 gODILYINJURY(Peraccident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
$
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4� OOO � OOO
B EXCESS LIAB CLAIMS-MADE AGGREGATE $ 4� OOO � OOO
DED X RETENTION$ 10,000 UP836G6071 8/20/2011 8/20/2012 $
C WORKERS COMPENSATtON WC STATU- OTH-
AND EMPLOYERS' LIABtLITY Y� N X TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1 OOO OOO
OFFICER/MEMBER EXCLUDED? ❑ N�A
(Mandatory in NH) 83021099 4/1/2012 4/1/2013 E.L. DISEASE - EA EMPLOYE $ 1 ��� ���
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 OOO OOO
A Leased/Rented Equipment 6609285A105 e/20/2011 8/20/2012 Limit $100 000
DESCRIPTtON OF OPERATtONS / LOCATtONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Re: Cleveland Street Phase II 08-0055-EN. City of Clearwater is listed as additional insured with
respects to General Liability subject to policy forms & conditions
CERTIFICATE HOLDER
(727)562-4755
City of Clearwater
PO Box 4748
Clearwater, FL 33758
ACORD 25 (2010/05)
INS025 nmm�s� n�
CANCELLATION
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
ly Petzold/BAILEY � �'� "i"�� � �� °��-
O 1988-2010 ACORD CORPORATION. All rights reserved.
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