CERTIFICATE OF LIABILITY INSURANCE (221)„�'�, OP ID: CA
'`�`_°R°Y CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YYYY)
08/15/12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATNELY 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
REPRESENTATNE 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
Hockman Insurance Agency, Inc.
3438 Colwell Avenue
Tampa, FL 33614
Hockman Insurance Agency, Inc.
INSURED Advanced Systems Engineering,
Inc.
13555 Automobile Blvd., #330
Clearwater, FL 33762
813-636-4
813-281-1
ADVAN04
iNSURERa:The Phoenix Ins. Co.
�r,suReR e: The Travelers Indemnity Co.
iNSUReR c: Travelers Casualty & Surety Co
�NSUReR o: Everest National Insurance Co.
INSURER E :
NAIC tt
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 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 SUB pOLICY NUMBER MM/DDY/YYYY MM/DDYYYYY LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO,OO
DAMA RENTED
l4 X COMMERCIAL GENERAL LIABILITY 6601C914015PHX � � � 08/17/13 pREMISES Ea occurrence $ 100,00
CLAIMS-MADE � OCCUR MED EXP (Any one person) $ 5,0�
��� � �o�� PERSONAL&ADVINJURY $ 'I,OOO,OO
GENERALAGGREGATE $ Y,OOO,OO
GEN'L AGGREGATE �UMIT APPLIES PER: �` �i g�y �pp� PRODUCTS - COMP/OP AGG $ Z�OOO�OO
POLICY X PRO- LOC �.d'S S'���e�L I�t� 6CU� D $
AUTOMOBILE LIABILI7Y a COMBINED SINGLE LIMIT $ �,OOO,OO
(Ea accident)
�1 ANY AUTO 6601 C914015PHX12 08/17/12 OS/17/13 BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE $
X HIREDAUTOS (Peraccident)
X NON-OWNED AUTOS
$
$
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ $,OOO,OO
EXCESS LIAB CLAIMS-MADE AGGREGATE $ $,OOO,OO
B XSFCUP395�T1981N�77 O8/17/12 . 08/17/13
DEDUCTIBLE $
X RETENTION $ � O,OOO $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY T RY IMIT _ ER
C ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N XVMPAUB3951T16212 08/17/12 08/17/13 E.L.EACHACCIDENT $ 5�0,��
OFFICER/MEMBER EXCLUDED? ❑ N � A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ SOO,OO
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ SOO,OO
p Professional 79AE007404121 03/10/12 03/10/13 Per Claim 2,000,00
Liability Ann Agg 2,000,00
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (AHach ACORD 101, Additional Remarks Schedule, iT more space is required)
Professional Liability coverage is written on a claims made and reported
basis. Certificate holder is listed as an additional insured with respects
to General Liability, Auto Liability, Excess Liability policies on a primary
and non-contributo�'y basis. Waiver of Subrogation in favor of the additional
insured applies to the GL, Auto Liab,Excess Liability, & WC Policy
TE HOLDER
City Of Clearwater
City Clerk
PO Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2009/09)
CITYOFC
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
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