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CERTIFICATE OF LIABILITY INSURANCE (200)Client#: 39357 HWLOC AC�RD.M CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDM'YY) 05/01/2012 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 Katie Johnson NAME: Construction - Remegi Team PHONE Fnx ,vc No ext : 312 595$200 ,,,�C, No): 312�595-4332 Mesirow Insurance Service ADpR�E�: kjohnson�mesirowfinancial.com 353 N. Clark Street — Chicago, IL 60654 INSURER(S) AFFORDING COVERAGE _ NAIC # • Travelers Indemnit Co of Amer 25666 INSURED H. W. Lochner, Inc. 20 N. Wacker Drive, Suite 1200 Chicago, IL 60606 INSURER A . j� �NSUReRe: St. Paul Fire& Marine Insuranc 24767 �n,suReRC: Travelers Casualty and Surety C 19038 �r,suaeRO: Charter Oak Fire Insurance Comp 25615 INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERl1FY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PO�ICY PERIOD INDICATED. NOTMTHSTANDING 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 POIICIES 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/DDlYYYY MM/DD/YYYY A GENERALLIABILITY P66084516877TIA12 5/01/2012 05/01/201 EACHOCCURRENCE $� �000�0 X COMMERCIAL GENERAL LIABILITY PREMISES�Ea occur° nce $1 OOO OOO CLAIMSMADE � OCCUR MED DCP (Any one person) $ rJ �� PERSONAL & ADV INJURY $ � ,OOO�OOO GENERAL AGGREGATE $Z,OOO,OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $Z�OOO�OOO POLICY X PR� LOC $ JECT p AUTOMOBILE LIABILITY P8108451 B877COF12 5/01/2012 05/01/201 COMBINED SINGLE LIMIT � O�O 00� Ea accident > > X ANY AUTO BODILY INJURY (Per person) $ ALLOWNED SCHEDULED BODILYINJURY(Peraccident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ g X UMBRELLA LIAB occuR ZUP10P6385412NF 5/01/2012 05/01/201 EACH OCCURRENCE $5 000 000 EXCESS LIAB CLAIMSMADE AGGREGATE $S OOO OOO DED X REfENTION$iO�OOO $ C WORKERSCOMPENSATION pqUB8976P38712 5/01/2012 05/01/201 X�STATU- OTH- AND EMPLOYERS' LIABILITY ANY PROPRIEfOR/PARTNER/IXECUTIVE Y� N E.L. EACH ACCIDENT $� OOO OOO OFFICER/MEMBER EXCLUDED? � NfA (Mandatory In NHJ E.L. DISEASE - EA EMPLOYEE $� ,��,�� If yes, describe under DESCRIPfION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $� OOO OOO DESCRIPTtON OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 107, Add'Rional Remarks Schedule, if more space is required) R��fD Re: City of Clearwater Job #2306 - Gas Design and permitting for US 41 (FPID #256324-1) Job #2413 - Gas Design and permitting for US 41 (FPID #418860-2) MAY 14 2012 Job #2860-SR 52 Suncoast to US 41 - Gas Design and Permitting The following is an additional insured as respects General Liability and (See Attached Descriptions) OFFICIAL RECpRDS AND /`FRTI�1(`ATF 41AI 11FR f`AN[:FI I ATIAAI City of Clearwater Attn: City Clerk P.O. Box 4748 Clearwater, FL 33758-4748 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 I � R �� O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #51136642/M1135733 K19 Client#: 39357 HW LOC DATE (MMIDD/YYYI� ACORD,M CERTIFICATE OF LIABILITY INSURANCE 05/01/2012 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 Katie Johnson NAME: Construction - Remegi Team PHONE 312 595�200 FAx 312-595-4332 A/C No EM : (A/C, No): Mesirow Insurance Service AoDR�ESS: kjohnson@mesirowfinancial.com 353 N. Clark Street INSURER(S) APFORDING COVERAGE NAIC # Chicago, IL 60654 iNSUReRa• Travelers Indemnity Co. ofAmer 25666 INSURED H. W. Lochner, Inc. 20 N. Wacker Drive, Suite 1200 Chicago, IL 60606 �r,suReR e: St. Paul Fire & Marine Insuranc 24767 iNSUReac: Travelers Casualty and Surety C 19038 ir,suReao: Charter Oak Fire Insurance Comp 25615 INSURER E : 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. NOTVNTHSTANDING ANY REQUIREMENT, TERM OR CONDITIONOF 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. INSR TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY A GENERAL LIABILITY P6608451 B877TIA12 5/01/2012 05/01/201 EACH OCCURRENCE $ � 0�0 0�0 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occED n� $1 OOO OOO CLAIMSMADE J OCCUR MED EXP (Any one person) $ rJ 0�0 PERSONAL 8 ADV INJURY $'I �OOO�OOO GENERALAGGREGATE $Z,OOO,OOO GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $Y,OOO,OOO POLICY X PR� LOC $ JECT p AUTOMOBILE LIABILITY P8108451 B877COF12 5/01/2012 05/01/201 COMBINED SINGLE LIMIT .� 000 000 Ea accideM + r X ANY AUTO BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ � AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ X HIRED AUTOS X AUTOS Per accident $ g X UMBRELLA LIAB occuR ZUP10P6385412NF 5/01/2012 05/01/201 EACH OCCURRENCE s5 000 000 EXCESS LIAB CLAIMSMADE AGGREGATE $S OOO OOO DED X REfENTION$'IO�OOO $ C WORKERSCOMPENSATION pqUB8976P38712 5/01l2012 05/01/201 X�STATU- OTH- AND EMPLOYER5 LIABILITY ANY PROPRIETOR/PARTNER/IXECUTIVE Y� N E.L. EACH ACCIDENT $� OOO OOO OFFICER/MEMBER EXCLUDED? � N / A (Mandatory in NHJ E.L. DISEASE-EA EMPLOYEE $�,��,��0 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE- POLICY LIMIT $'I OOO OOO DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (Attach ACORD 101, Adtlitional Remarks Schedule, if more space is requlred) Re: Engineering Services Contract. The following are included as Additional Insureds on the General �� I�� Liability Policy per written contract: City of Clearwater. '�� A Waiver of Subrogation applies to the Workers Compensation Policy per written contract. MAY i 5 2012 ----�------ �--- --- �--.,.�. . .�.,... ,� City of Clearwater City Clerk 100 South Myrtle Ave. 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 I� F' ��''�'I�j` �O 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010l05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S 1136643/M1135733 ❑ K19