CERTIFICATE OF LIABILITY INSURANCE (310)Received
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ACORDon CERTIFICATE OF LIABILITY
INSURA� DATE(MM/DD/YYYY)
an Y Bert®
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
Saginaw Bay Underwriters
Commercial Lines
1258 S. Washington P.O. Box 1928
Saginaw, MI 48605
CONTACT Russ R. Atkinson
NAME:
PHONE 989 752 -8600 FAX
(A/C, No, Ext): (A/C, No):
E-MAIL
ADDRESS:
PRODUCER
CUSTOMER ID #:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURED
R. Roese Contracting Co., Inc.
P.O. Box 158
Kawkawlin, MI 48631
INSURERA: CNA Insurance Companies
Safety Indemnity
American Sae
INSURER B : •7 Co.
5099245245
INSURER C :
03/15/2015
INSURER D :
$1,000,000
$100,000
INSURER E :
DAMAGE TO
PREMISES (Ea RENTED
INSURER F :
CLAIMS -MADE
OVERAGE
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
kTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
pm)
POLICY NUMBER
POLICY EFF
$MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMBS
A
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
OCCUR
5099245245
03/15/2014
03/15/2015
EACH OCCURRENCE
$1,000,000
$100,000
X
DAMAGE TO
PREMISES (Ea RENTED
CLAIMS -MADE
X
MED EXP (Any one person)
$5,000
X
PD Ded: $10,000
PERSONAL & ADV INJURY
$1,000,000
GENERAL AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$2,000,000
POLICY X IF T LOC
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
Drive Other Car
509924523/15/2014
(�y 4
77��
4,E'9 i aCi 1,, :, CO a g .:
wd+i'O 0
LECISUOVE S_ k ;T"'c.; irr
a`� -
Fj :;
r G"
03/15/2015
COMBINED SINGLE LIMIT
(Ea accident)
$
1,000,000
$
X
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
X
X
$
X
$
A
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
5099245262
03/15/2014
03/15/2015
EACH OCCURRENCE
$5,000,000
AGGREGATE
$5,000,000
DEDUCTIBLE
RETENTION $ $0
$
_
X
$
A
WORKERS COMPENSATION
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS
Y I N
Y
N/A
5099245259
03/15/2014
03/15/2015
X WC Y I IMIT OTH-
ER
TORY I IMITS
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE - EA EMPLOYEE
$1,000,000
below
E.L. DISEASE - POLICY LIMIT
$1,000,000
A
B
Lease /Rented Epmt
Pollution Liab
5099245245
CPL0249001302
03/15/2014
02/23/2013
03/15/2015 600000 Limit/5000 Ded
02/23/20161 1000000 Limit/10000 Ded
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space s required)
City of Clearwater is included as Additional Insured with respects to the General Liability as their
interests may appear as required by written contract.
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Attn: City Manager
100 S. Myrtle Ave, 3rd Floor
Clearwater, FL 33756 -5520
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
ACORD 25 (2009/09) 1 of 1
#S283348/M28321 3
"d'I$88- 009 ORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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