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COMPRESSED NATURAL GAS FILLING STATION UPGRADES RFP 10-13 - 13-0032-GA - CERTIFICATE OF LIABILITY INSURANCEA c° CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 03/03/2014 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 CERTICATE 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 YouZoom Insurance Services Inc. 7045 College Blvd., 4th floor Overland Park, KS 66221 Fax:877- 835 -1833; PH: 888 - 240 -8803, Option 1 CONTACT Arrowhead Automotive Aftermarket Service Center NAME: (A/HONE o. EXT): 888-240 -8803 FAX No): 877-835-1833 E -MAIL arrow AMServiceCenter head com ADDRESS: G 9rP• INSURER(S) AFFORDING COVERAGE NAIC # INSURED 0150214 -00 PHOENIX ENERGY 164 LEWIS LAKE LANE PELL CITY, AL 35125 INSURER A: Universal Underwriters Insurance Company 41181 INSURER B: Universal Underwriters of Texas Ins. Co. 40843 INSURER C: EACH OCCURENCE INSURER D: DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E: ❑❑ CLAIMS MADE l tl OCCUR 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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE JN01112200p ADD'LSUBR POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS A GENERAL LIABILITY • COMMERICAL GENERAL LIABILITY ❑ ❑ 328767 ��''''��'I' CWE 4 04/01/2014 't -a) \/ ') H 9 1S 04/01/2015 EACH OCCURENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ ❑❑ CLAIMS MADE l tl OCCUR MED EXP (Any one person) $ ❑— ❑ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ - GEN'L AGGREGATE LIMIT APPLIES PER: ❑ POLICY ❑ PROJECT ❑ LOC PRODUCTS - COMP/OP AGG $ A AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED AUTOS ❑ ❑ lY /'4j,, aphOpd. v r 7r: �', "(! " \ r .� 32 wS' t �" I tJ k. o' O ` -LF Uzi ,4,1, �;' j04/01/2015 COMBINED SINGLE LIMIT (Ea Accident) $1 ,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ � � SCHEDULED AUTOS PROPERTY DAMAGE (Per accident) $ HIRED AUTOS I NON -OWNED AUTOS El l COMP /COLL DED $ / $ $ A ❑ UMBRELLA LIAB 0.1 OCCUR EXCESS LIAR ❑ CLAIMS -MADE ❑ ❑ 328767 04/01/2014 04/01 /2015 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ DEDUCTIBLE l.I RETENTION $ 0 PRODUCTS - COMP /OP AGG $ 3,000,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE Y/ N OFFICER/MEMBER EXCLUDED? - ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A ❑ WC STATU- TORY LIMITS ❑ OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A GARAGE LIABILITY El I ANY AUTO ❑ ❑ 328767 04/01/2014 04/01/2015 OTHER THAN AUTO ONLY EACH ACC: $ 1,000,000* A CUSTOMER AUTO-DIRECT PRIMARY ❑ ❑ 328767 04/01/2014 04/01 /2015 $ 300,000 Limit DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Reason for Certificate: General Liability. See Additional Remarks Schedule Attached CERTIFICATE HOLDER CANCELLATION THE CITY OF CLEARWATER PO BOX 4748 CLEARWATER, FL 33756 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 YouZoom Insurance Services Inc. ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION, All rights reserved The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION, All rights reserved The ACORD name and logo are registered marks of ACORD AMR Er AGENCY CUSTOMER ID: 0150214 -00 LOC #: ADDITIONAL REMARKS SCHEDULE Page_3_of 3_ AGENCY YouZoom Insurance Services Inc. NAMED INSURED PHOENIX ENERGY 164 LEWIS LAKE LANE PELL CITY, AL 35125 POLICY NUMBER 328767 CARRIER Universal Underwriters Insurance Company NAIC CODE 41181 EFFECTIVE DATE: 04/01/2014 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate Of Liability Insurance *Products — Completed Operations Aggregate of $3,000,000 applies to the Garage Liability. CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED. CUSTOMER AUTO INCLUDES GARAGE KEEPERS. ACORD 101 (2008/01) © 2008 ACORD CORPORATION, All rights reserved. The ACORD name and logo are registered marks of ACORD