CERTIFICATE OF LIABILITY INSURANCEA� � DATE (MMIDDIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 11i2,i2o12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HO�LDER. 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 WAIVE[I, 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 JE= NO 018
NAME: rY Y
Greyling Inaurance Brokerage PHO"E .(770) 552-4225 F� .(866)e;so-4oes
450 Northridge Parkway E-AAi41L . jerry.aoyolaQgreyliag.com
S111tE ZOZ INSURE S AFFORDINGCOVERAGE NAICM
Atlaiita GA 30350 �NSUReRa�National IInion Fire Ins. Co. 19445
INSURED
Kimley-Hora and Associates, Iac.
P.O. Sox 33068
Ral
NC 27636
& Iadustxv Iasurance 119410
Insurance
7
COVERAGES CERTIFICATE NUMBER:12-13 (Kimley Sharda) REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUGD TO THE INSURED NAMED ABOVE FOR THE POI.ICY 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.
��7� TYPE OF INSURANCE ADDL UBR POLICY EFF POLJCY EXP LIMRS
POLICY NUMBER M
GENERALLIABILITY X X EACHOCCURRENCE $ 1,000,000
X CAMMERCIAL GENERAL LIABII.IN P M� ES Ea occ Dnc $ SOO, OOO
A CLAIMS-MADE Q OCCUR 9645227 12/1/2012 /1/2013 MEDEXP An one erson $ _ 2$, 000
X COAti8Ctu81 LiBbility PERSONAL BADV INJURY $ 1, OOO, OOO
GENERAL AGGREGATE $ 2� OOO � OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2� OOO , OOO
POLICY X PR� X LOC $
AUTOMOBILE IJABILITY ]( ]( EOMBI�N�ED SINGLE LIMfT 1 OOO OOO
A X ANY AUTO BODILY INJURY (Per person) $
ALLOWNED SCHEDULED 982985 12/1/2012 /1/2013
AUTOS AUTOS BODILY INJURY (Per accident) $
X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE $
AUTOS P r cciden ,
$
X UMBRELLA LIAB X OCCUR X X EACH OCCURRENCE $ S, OOO, OOO
B EXCESS LJAB CLAIMS-MADE AGGREGATE $ . 5, OOO � OOO
DED X RETENTION 10,00 8 021730741 12/1/2012 /1/2013 $
C' WORKERS COMPENSATION g X WC STATU- OTH-
AND EMPLOYERS' LIABILITY
ANYPROPRIETORIPARTNERIEXECUTIVE Y�N E.L.EACHACCIDENT $ 1 OOO OOO
OFFICER/MEMBEREXCLUDED? � N�A 12/1/2012 /1/2013
(Mandatory In NH) 18112556 E.L. DISEASE - EA EMPLOYE $ 1 OOO OOO
H yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1 000 000
D PrOfeseloIISl LiBbility X 16017332 12/1/2012 /1/2014 perGaim $2,000�000
Aggregate $2, 000, 000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Addltlonal Remarks Schedule, If more space Is required)
Re: RFQ 16-12, Geaeral Bagineeriag Services; Nizar Jetha. The City of Clearwater ia named as am
Additional Inaured on the above referenced liability policies with the exceptioa of workers comg>easatioa
& professioaal liability where required by written contract.
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CERTIFICATE
City of Clearwater
City Clerk
P.O. Box 4748
Clearwater, FL 33758
SHOULD ANY OF THE ABOYE DESCiiI��D P �L�/l'I�fCE4.LED BEFORE
THE EXPIRATION DATE �IHERHOf�y��MEi.T����l�� DI2iLIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
tias Ormaza/JBRRY
ACORD 25 (2070/05) O 1988-2010 ACORD CORPORATION. All ri�hts reserved.
INS025 (zoioo5).oi The ACORD name and logo are registered marks of ACORD