CERTIFICATE OF LIABILITY INSURANCE (226)CERTIFICATE OF LIABILITY INSURANCE I o°�Tn'MMro°""'"'
THIS CERTIFIC�,TE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOI_DER. 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
REPRESENTATI'✓E OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If �:he certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, suibject to
the terms and cc�nditions of the policy, certain policies may require an endorsement. A statement on this certificate dces not confer rights to the
certificate holdei• in lieu of such endorsement(s).
PRODUCER
3rown & Brown Insurance - Clearwater
igale@bbpinellas com
' O Box 2456
;learwater FL 33 i 57-2456
INSURED
Kisinger Campo 8 Assoc. Corp.
KCCS, Inc
201 N. Franklin Street, Ste 400
Tampa FL 33602
INSURER E :
AFFORDING COVERAGE I NAIC #
COVERAGES CERTIFICATE NUMBER: 19R4f415�� 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 ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR NND POLICY NUMBER MM/DD/YYYY MMIDDIYWY LIMITS
A GENERnL LIABILIrv 1 UUNAG7547 /1/2012 !1/2013 Ep,CH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILIN DAMAGE T RENTED
PREMISES Ea occurr nc 5100,000
CLAIMS-MADE � OCCUR MED EXP (An one person) $10,000
X ContractualLiab PERSONAL&ADVINJURY $1,000,000
Rp/�� GENERALAGGREGATE $2,000,000
�
GEN'L AGGREGATE LIMIT APPLIES PER: ���ol PRODUCTS - COMP/OP AGG $2,000,000
X POLICY PR� LOC $
A AUTOMOBILE LIABIUTY 21UENNE3246 ��G 3 � 2 1�012 /1/2013 Ea accident 1,000,000
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED
AUTOS AUTOS nC �1 �C /''°� BODILY INJURY (Per accident) $
X X NON-OWNED �t f��Ii GI. 1�-�+ ��� PROPERTYDAMAGE $
HIRED AUTOS AUTOS e=py_q�ro pT1�,fC S� �L� Per accident
L.4��R3lJ'111 tl' i $
B UMBRELwLIns X OCCUR 21XHUAG7607 /1/2012 /1/2013 EqCHOCCURRENCE $3,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $3,000,000
DED X RETENTION$10,000 $
q WORKERS COMPENSATION 1 WBNW1033 10/3/2012 0/3/2013 X WC STATU- OTH-
AND EMPLOYERS' LIABILITY Y I N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500,000
OFFICER/MEMBER EXCLUDED? ❑ N I A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $500,000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000
C Professional Liability EH288295813 1/2/2011 1/2/2012 Per Claim 2,000,000
Claims Made ' Aggregate 5,000,000
Deductible 200,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Certificate Holder is an additional insured with respect to general liability ,auto liability and umbrella liability. Endorsements available upon
request. Waiver of Subrogation applies to general liability and workers compensation. Explosion,Collapse & Underground hazard included in
CGL. "10 Days for Non Payment.
SERVICES UNDER ENGINEER OF RECORD AGREEMENT, RFQ #16-12 AND ALL TASK WORK ORDERS THEREUNDER (KCA
#6201207.00)
CERTIFICATE
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF CLEARWATER ACCORDANCE WITH THE POLICY PROVISIONS.
ATTN: CITY CLERK
P O BOX 4758 AUTHORIZED REPRESENTATIVE
CLEARWATER FL 33758-4748
�nan. 7�. 5�t�
O 7988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD