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GREENLEA EAST-WEST INTERCONNECT RECLAIMED WATER PROJECT - 10-0038-UT - CERTIFICATE OF LIABILITY INSURNACE Client#: 1462194 132ANDRESIT DATE(MM/DD/YYYY) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 1 5/01/2012 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 Karie Evans NAME: BB&T-Oswald Trippe and Company P HONE 239-433-7179 FAX 866-802-8680 A/C,No,Ext: (A/C,No): 13515 Bell Tower Drive E-MAIL KLEvans @BBandT.com Fort Myers, FL 33907 INSURER(S)AFFORDING COVERAGE NAIC# 239 433-4535 INSURERA:Westfield Insurance Company 24112 INSURED INSURER B: Florida Citrus Business&Indus WCSIF Andrew Site Work LLC INSURER C 4696 Elevation Way INSURER D Fort Myers, FL 33905 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION 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 CONTRACTOR 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.ADDLSUBR LTR TYPE OF INSURANCE NSR WVD POLICY NUMBER POLICY EFF POLICY EXP LIMITS (MM/DD/YYYY) (MM/DD/YYYY) A GENERAL LIABILITY X CWP4547425 9/15/2011 09/15/2012 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE To RENTED occurrence) $150,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $10,000 X PD Ded: $1,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO- MID LOC $ JECT A AUTOMOBILE LIABILITY CWP4547425 9/15/2011 09/15/201 (CEO,acc S iden INGLE LIMIT $1'000'000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ A X UMBRELLA LAB X OCCUR CWP4547425 9/15/2011 09/15/2012 EACH OCCURRENCE s2,000,000 EXCESS LAB CLAIMS-MADE AGGREGATE s2,000,000 DED I X RETENTION$0 $ B WORKERS COMPENSATION 10644921 4/01/2012 04/01/201 X &Sy AMITS ER AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: Greenlea East West Interconnect Project Contract 10-0038-UT City of Clearwater is named as an additional insured with interest in insured's operations with respects to General Liability only, per blanket additional insured endorsement form CG2033. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION The City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 112 S. Osceola Avenue ACCORDANCE WITH THE POLICY PROVISIONS. Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S8562148/M8527772 KAEV DESCRIPTIONS (Continued from Page 1) **Workers Comp Information** Proprietors/Partners/Executive Officers/Members Excluded: Adam Youschak, Member and Richard Youschak, Member SAGITTA 25.3(2010/05) 2 of 2 #S8562148/M8527772