CERTIFICATE OF LIABILITY INSURANCE (10)�� � CERTIFICATE OF LIABILITY INSURANCE 6;�;2`oi2°��'
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
NAME:
BY'OWri & BY'OWri Insurance - Clearwater PHONE FAX
P.O. Box 2456 a�c No ext:727-461-6044 (A�c,No):727-442-7695
E-MAIL
SU1t.2 660 ADDRESS:
Clearwater FL 33757-2456 PRODUCER
CUSTOMER ID #:
INSURED
King Engineering Assoc., Inc.
4921 Memorial Hwy Ste 300
Tampa FL 33634
COVERAGES
CERTIFICATE NUMBER: 933309056
INSURER(S) AFFORDING COVERAGE NAIC #
iNSUReRa:National Fire Ins of Hartford 20478
iNSUReRe:Trans ortation Insurance Co. 20494
iNSUReRC:Valle For e Insurance Com an 20508
INSURER D :
INSURER E :
INSURER F :
1:7=V/6�[�l���l�l��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/YYY MM/DD/YYY
A GENERAL LIABILITY C2066728229 1/1/2012 1/1/2013 EACH OCCURRENCE $l, 000, 000
X COMMERCIALGENERAL LIABILITY DAMAGETO RENTED 500, 000
PREMISES Ea occurrence $
CLAIMS-MADE � OCCUR MED EXP (Any one person) $5, 000
X XCU Included PERSONAL &ADV INJURY $l, 000, 000
GENERALAGGREGATE $2,000,000
GEN'LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2,000,000
POLICY X PRO- LOC $
JECT
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 X UMBRELLA LIAB X OCCUR C2066728246 1/1/2012 1/1/2013 EACH OCCURRENCE $5, 000, 000
EXCESSLIAB CLAIMS-MADE AGGREGATE $5,000,000
DEDUCTIBLE $
X RETENTION $0 $
� WORKERSCOMPENSATION WC163672015 1/1/2012 1/1/2013 X WCSTATU- OTH-
AND EMPLOYERS' LIABtLITY Y� N TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $l, 000, 000
OFFICER/MEMBER EXCLUDED? � N �A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $l, 000, 000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $l, 000, 000
A Leased/Rented Equipment C2066728229 1/1/2012 1/1/2013 Per Item $100,000
Maximum $100,000
Deductible $2,500
DESCRIPTION OF OPERATtONS / LOCATtONS / 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 Ol/09
(attached). Additional Insured status also applies to Auto Liability. Waiver of Subrogation for General
See Attached...
CERTIFICATE HOLDER
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.
City of Clearwater
Attn: Engineering
PO BOX 4748 AUTHORIZED REPRESENTATIVE
Clearwater FL 33758-4748
%Y�,L2<.,�. ��C
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC #:
",� +�
�'���' ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMEDINSURED
Brown & Brown Insurance - Clearwater King Engineering Assoc., Inc.
4921 Memorial Hwy Ste 300
POLICYNUMBER Tampa FL 33634
CARRIER
ADDITIONAL REMARKS
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
POLICYNUMBER: 0 20667 28 2 29 CG 24 04 10 93
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
WAIVER F TRANSFER
F RECOVERY AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
ANY PERSON OR ORGANIZATION WITH WHOM YOU
AGREE IN WRITING TO WAIVE YOUR RIGHT TO
RECOVER AGAINST THEM. YOU MUST AGREE TO
THIS WAIVER PRIOR TO THE DATE OF LOSS.
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
The TRANSFER OF RIGHTS OF RECOVERY AGAINST because of payments we make for injury or damage arising
OTHERS TO US Condition (Section IV--COMMERCIAL out of your ongoing operations or"your work"done under a
GENERAL LIABILITY CONDITIONS) is amended by the contract with that person or organization and included in the
addition of the following: "products-completed operations hazard." This waiver
We waive any right of recovery we may have against the applies only to the person or organization shown in the
person or organization shown in the Schedule above Schedule above.
ry
6
n
n
d
N
Ot
6
O
O
V
A�
MAC
CG 24 04 10 93 Copyright, Insurance Services Office, Inc., 1992
ki t4Uss10 uIUy .Policy #C2066728229 Wage i oiz
CIVA
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE(OPTIONAL)
Name of Additional Insured Persons)
Or Organizations
(As required by written contract(agreement per Paragraph A. below.)
Locations)of Covered Operations
(As per the written contra ctlagreement, provided the location is within the"coverage territory"of this Coverage
Part)
(Coverage under this endorsement Is not affected by an entry or lack of entry in the Schedule above.)
A. Section II -Who Is An Insured is amended to include as an additional insured any person(s)or organization
(s), including any person or organization shown in the Schedule above, whom you are required to add as an
additional insured on this Coverage Part under a written contract or written agreement, provided:
a. The written contract or written agreement was executed prior to:
1. The"bodily injury"or"property damage"; or
2. The offense that caused the"personal and advertising injury"
for which the additional insured seeks coverage under this Coverage Part; and
b. The written contract or written agreement pertains to your ongoing operations or "your work" for the
additional insured(s).
B. The insurance provided to the additional insured is limited as follows:
1. The person or organization is an additional insured only with respect to liability for"bodily injury,""property
damage,"or"personal and advertising injury"caused in whole or in part by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on your behalf
in the performance of your ongoing operations for the additional insured(s)or
c. "Your work" that is included in the "products-completed operations hazard" and performed for the
additional insured, but only if this Coverage Part provides such coverage, and only if the written
contract or written agreement requires you to provide the additional insured such coverage.
2. However, we will not provide the additional insured any broader coverage or any higher limit of insurance
than the least of those:
a. Required by the written contractor written agreement;
b. Described in 8.1, above; or
c. Afforded to you under this policy,
http://fon net-ci.cna.com/glhtm/ena7788.ht 1/8/2010
Ci140331B 0189 rage 2 of z
3, This insurance is excess of bll other insurance available to the additional insured, whether primary,
excess, contingent or on any other basis, unless the written contract or agreement requires this insurance
to be primary. In that event, this insurance will be primary relative to insurance which covers the
additional insured as a named insured. We will not require contribution from such insurance if the written
contract or written agreement also requires that this insurance be non-contributory. But with respect to all
other insurance under which the additional insured qualifies as an insured or additional insured, this
insurance will be excess.
4. The insurance provided to the additional insured terminates when your operations for the additional
insured are complete. But if the written contract or written agreement specifies a date until which this
insurance must apply, then this insurance terminates:
a. On the date specified in the written contract or written agreement; or
b. When this policy expires or is cancelled,
whichever occurs first.
C. With respect to the insurance afforded to the additional insured, the following additional exclusions apply.
This insurance does not apply to:
1. "Bodily injury," "property damage," or"personal and advertising injury" arising out of the rendering of, or
the failure to render, any professional architectural, engineering, or surveying services, including:
a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports,
surveys,field orders, change orders or drawings and specifications; and
b. Supervisory, inspection, architectural 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 specifically listed as an additional insured on another endorsement
attached to this Coverage Part.
D. SECTION IV—COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows:
1. The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the
following additional conditions applicable to the additional insured:
An additional insured under this endorsement will as soon as practicable:
(1) Give us written notice of an "occurrence" or an offense which may result in a claim or"suit" under this
insurance, and of any claim or"suit"that does result;
(2) Tender the defense and indemnity of any claim or "suit" to any other insurer or self insurer whose
policy or program applies to a loss we cover under this Coverage Part;
(3) Except as provided in Paragraph B.3 of this endorsement, agree to make available any other
insurance the additional insured has for a loss we cover under this Coverage Part; and
(4) Send us copies of all Legal papers received, and otherwise cooperate with us in the investigation,
defense, or settlement of the claim or"suit."
We have no duty to defend or indemnify an additional insured under this endorsement until we receive
from the additional insured written notice of a claim or"suit."
2, With respect only to the insurance provided by this endorsement, the first sentence of Paragraph 4.a. of
the Other Insurance Condition is deleted and replaced with the following:
4. Other Insurance
a, Primary Insurance
This insurance is primary and non-contributory except when rendered excess by this
endorsement, or when Paragraph b. below applies.
E. The provisions of the written contract or written agreement do not in any way broaden or amend this
Coverage Part.
http://1'ormnet-ci.cna.com/glhtm/ena7788.htm 1/8/2O t O