CLEARWATER CONCENTRATE INJECTION DEEP WELL PROJECT PHASE 2 - 09-0044-UT - CERTIFICATE OF LIABILITY INSURANCE y y y
7A 11-1
ACORL)f CERTIFICATE OF LIABILITY INSURANCE w1I, v1T
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS P40 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), AUTHORtZEt)
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IVPORTANT: If the Certificate holder Is an ADDITIONAL INSURED,the policy(iaa)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 Ifeu of such endorsomengs).
PRODUCER CONTACT
N Kristen Dayton
!AM E:
M. E. wilcon Cc.. Inc,
300 W. PI&I.c St= A00RESS, kdayton@m&wils=.c=
Ste 200 INSURERy$p AFFORDING COVERAGE NATO N
Tampal FL 33606 INSURER A, Westfield :rns cc 24112
INSURED INSURER 9: Zeni:h T-ns ':a 13269
Apolied Drilling TDgineCering, Znc;. INSURER C
10014 4. Ladle Mabry INSURER CS, ......
suite 2015 INSURER,Z,
TiSWa, FE, 33618 IINSURER F:
COVERAGES CERTIFICATE NUMBER: 33762073 REVISION NUMBER:
THIS IS TC,f,FP76F-V THAT THE POLICIES OF lNSuR&14`CE-USTED qFrF'p� aEpI ISSUED TO THE IflSUREG NAINIED ABOVE LC P,THE POLICY PER40D
NMCATED, 'ADI6041STANDRIG ANY REOUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTJ-IER DOCU-NIEENT WITH RESFECT 10 WHICII THIS
CERTIrICATE MAY BE ?S%JED OR 141AY PERTAA, THE INSURANCE AF-C)RrED BY THE POLICIES DEESCRIDED HEREIN IS SUBJECT TO ALL THE TERMS,
EXC LU 6 MKID 00NDI IONS O=SUCH POLICIES,LlmlTS si-,,0,NN MAY HAVE BEEN REDUCED BY PAID CLAIMS
POL4 Y E FF poocy E XP
INiR- TYPE or OUCY NUM SER IM2WODNyyy MIMM011yleyv -`mTS
LIM
A OFNERALLIAU1,0TY TR2,a,5 714 6 7 1 14 F A C'CCUR P F N C C $1,On,000
LIAVA3L"01 REN T&
$150,000
X ,,rIIAERCEA� �ENERAL LIAIRIL�P(
171, NiEri LAP�A� $ 10,000
CLPI,454CAADE I",R one P.4m,),
x $5130 dedu�_tible 000,00o,
rl ERSC�NAL ADV INiURY ;$
A,
F
CENE54,1�AGGREGATF
Gf N'L AG�,,RE -F F, IT`14PT APO II PS SF FR
2,OOU,ODD
V� F1R0F1,UCT$-COMP AGG
F-Ri
jj� LOC
01/01/13 Glf�,1/141 COM&HED ZM5ILL�-•?Al
K AU-VOMQ RILE LIAO�LITY TrA1171,1 (EIi azddant} $1,000,000
BODILY NSURY L CH ix AN Y A Ll CC,
ALLCYVOIED ESCHEOU6 ELI BODCLY RY ft.-aczidon�},It
AUTW-, AuT 03,
X N0N,0`/VNED - - - - -----I-
--- --
AUTO-a' CITE tDww� ---- - -
PIP -4
A 'X UMBIRELLA L1A.zA x 01/01/13 01101114 EACH OCCURRENCE 5,000,000
"r-e$S L"
AQ�G RE f'SATE 5 5,000,000
i qtr
R f�,T F r,14
WORKER COMPENSATION Z068841607 Illldl113 01101/14 X V%, STA70- C,1'H-
ANO EMPLOYERZ'41A69LITY Y'N - -_TCL1KYIF1SlITO, ,—EB-- ---, -
ANY PRQPPIJE r I r FEE LL EACH ACCIDENT !$
QFF1CF.R4A--F,1Z,ER NIA
IMapdatoy w NHl E C-❑iEEASE-EA EV Pi '(E E$ 1,000,000
IF T
$
EL D�SfASE-POLICY PAII
A Leased Y Renter d ST-,i pzo n t -RA 3 57 14 67 175,000
DZSCR€PTION Qf OPERAM(0145!LOCAMONS,VEHICLES tAfiacfi ACORD 101,Additional Raffafk3 Schadule,iP more 6pata It("U;radl
project. Cleat-water Catce=rate laiectior, Deep Well Proj Ct Phase 11
Project#: 09-0044UT
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ASOVE DESCRIBED POLICIES Sr.CANCELLED BEFORE
City of Claarwater THE EXPIRATION DATE THEREOF, NOTICE VVILL BE DELIVERED IN
ACCORDANCE WITH TIHE POLICY PROVISIONS.
100 South •yrtle Aven,,a AUTHOR,1ZED REPRESENTATNE
Suite 220
Cleazwatet, FL 3E756
F,ISA
(D 1988-2010 ACORO CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
KDOOl
33762073