CERTIFICATE OF LIABILITY INSURANCE (417)No 102 REVISED
Louisiana certificate form:
LDI COI 280990 01 12
CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YY)
9/13/2013
PRODUCER
Point Clear Insurance Services LLC
368 Commercial Park Drive
Fairhope, AL 36532 -1910
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY
A THE GRAY INSURANCE COMPANY
INSURED
CrowderGulf Joint Venture
5435 Business Parkway
Theodore, AL 36582 -1675
COMPANY
B
COMPANY
C
COMPANY
D
COVERAGES
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.
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MM/DDYY)
POLICY EXPIRATION
DATE (MMIDD/YY)
LIMITS
A
GENERAL
LIABILITY
COMMERCIAL GENERAL
LIABILITY
OWNERS & CONTRACTOR'S
PROT
XSGL -073375
9/1/2011
9/1/2014
GENERAL AGGREGATE
Unlimited
X
PRODUCTS — COMP /OP AGG
$3,000,000.00
PERSONAL & ADV INJURY
$1,000,000.00
EACH OCCURRENCE
$1,000,000.00
$50,000.00
FIRE DAMAGE (Any one fire)
MED EXP (Any one person)
$5,000.00
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
XSAL -074072
9/1/2011
,..9/1/2014
COMBINED SINGLE LIMIT
$1,000,000.00
X
BODILY INJURY
(Per person)
X
BODILY INJURY
(Per accident)
X
X
PROPERTY DAMAGE
GARAGE
LIABILITY
ANY AUTO
AUTO ONLY — EA ACCIDENT
OTHER THAN AUTO ONLY
EACH ACCIDENT
AGGREGATE
A
EXCESS
LIABILTY
UMBRELLA FORM
OTHER THAN UMBRELLA
FORM
GXS -042855
9/1/2013
9/1/2014
EACH OCCURRENCE
$4 000,000.00
AGGREGATE
$4,000,000.00
X
A
WORKER'S COMPENSATION
EMPLOYERS' LIABILITY
THE PROPREITOR/
PARTNERS/EXECUTIVE
OFFICERS ARE
AND
INCL
EXCL
XSWC-070696
9/1/2011
9/1/2014
X I Wow u� I I ERH
EL EACH ACCIDENT
$1,000,000.00
$1,000,000.00
EL DISEASE — POLICY LIMIT
X
EL DISEASE — EA EMPLOYEE
$1,000,000.00
I I
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES /SPECIAL ITEMS
The certificate holder is an additional insured on an policies except Workers' Compensation and is provided a Waiver of Subrogation, an if required by written contract The above insurance policies shall be
primary and noncontributory to any other insurance policies maintained by the certificate holder, if required by written contract
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Attn: City Clerk
P. O. Box 4748
Clearwater, FL 33758
In the event of cancellation by The Gray Insurance Company and if required by written
contract, 30 days written notice will be given to the Certificate Holder.
AUTHORIZED REPRESENTATIVE
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TH Y INSURANCE , PANY
Louisiana certificate form:
LDI COI 280990 01 12
CERTIFICATE OF INSURANCE Page 2
THE GRAY INSURANCE COMPANY
The below coverages apply if the corresponding policy number is indicated on the previous page.
A. Commercial General Liability
General Liability Policy Includes:
Blanket Waiver of Subrogation when required by written contract.
Blanket Additional Insured (CGL Form# CG 20 10 11 85) when required by written contract.
Primary Insurance Wording Included when required by written contract.
Broad Form Property Damage Liability including Explosion, Collapse and Underground (XCU).
Premises /Operations
Products /Completed Operations
Contractual Liability
Sudden and Accidental Pollution Liability
Occurrence Form
Personal Injury
"In Rem" Endorsement
Cross Liability
Severability of Interests Provision
"Action Over" Claims
Independent Contractors coverage for work sublet
Vessel Liability - Watercraft exclusion has been modified by the vessels endorsement on scheduled
equipment.
General Aggregate applies per project or equivalent.
B. Automobile Liability Policy Includes:
Blanket Waiver of Subrogation when required by written contract.
Blanket Additional Insured when required by written contract.
C. Workers Compensation Policy Includes:
Blanket Waiver of Subrogation when required by written contract.
U.S. Longshoremen's and Harbor Workers Compensation Act Coverage
Outer Continental Shelf Land Act
Jones Act (including Transportation, Wages, Maintenance, and Cure),
Death on the High Seas Act & General Maritime Law.
Maritime Employers Liability Limit: $1,000,000
Voluntary Compensation Endorsement
Other States Insurance
Alternate Employer /Borrowed Servant Endorsement
"In Rem" Endorsement
Gulf of Mexico Territorial Extension
D. Excess Liability Policy Includes:
Coverage is excess of the Auto Liability, General Liability, Employers Liability, & Maritime Employers
Liability policies
Blanket Waiver of Subrogation when required by written contract.
Blanket Additional Insured when required by written contract.
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