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CERTIFICATE OF LIABILITY INSURANCE (15)________, ® '`` °R° CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) �19nD14 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 Aon Risk Services Northeast, Inc. New York NY Office 199 water Street New York NY 10038 -3551 USA CONTACT NAME: PHONE (866) 283 -7122 I FAX (800) 363 -0105 (A/C. No. Ext): (A/C. No.): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Cellco Partnership d /b /a Verizon wireless 15505 Sand Canyon Ave. Irvine CA 92618 USA INSURER A: National Union Fire Ins CO of Pittsburgh 19445 INSURER B: NeW Hampshire Ins Co 23841 INSURER C: Illinois National Insurance Co 23817 INSURER D: $1,000,000 INSURER E: $2,000,000 INSURER F: 1 CLAIMS -MADE X COVERAGES CERTIFICATE NUMBER: 570054216753 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. Limits shown are as requested INSR LTR TYPE OF INSURANCE ADDL INSIZ SUBR WVD POLICY NUMBER POLICY EFF DD/YYYY1 POLICY EXP f MM/DDIYYYYJ LIMITS A X COMMERCIAL GENERAL LIABILITY GL7266932 (�7f (. _'., \ J� - ) -° " 06A30/2014 -+ 06/30/2015 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $2,000,000 1 CLAIMS -MADE X OCCUR X XCU Included MED EXP (Any one person) $10,000 PERSONAL &ADV INJURY $1,000,000 GGEEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO- JECT OTHER: ❑ LOC 1 GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP /OP AGG $2,000,000 '4 A A AUTOMOBILE x — _ LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS — _ SCHEDULED AUTOS NON -OWNED AUTOS CA 3504 8 L ;,. +- '- AOS CA 350 -06 -59 MA CA 350 -06 -60 VA 06/330/20,14 06/30/2014 06/30/2014 06/30/2015 06/30/2015 06/30 /2015 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY ( Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE AGGREGATE DED I 'RETENTION B A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR OFFICER/MEMBER IEXCLUDED? CUTIVE YNN (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA WCO26035004 AOS WCO27527697 CA 06/30/2014 06/30/2014 06/30/2015 06/30/2015 X I STATUTE I 0TH E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE -EA EMPLOYEE $1,000,000 E.L. DISEASE- POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) NAMED INSURED INCLUDES: GTE MOBILNET OF TEXAS. RE: COUNTRYSIDE CELL SITE - CROWN CASTLE SITE BUN #814424 CERTIFICATE HOLDER IS ADDITIONAL INSURED (EXCEPT ON WORK COMP) AS RESPECTS OPERATIONS OF THE NAMED INSURED TO THE EXTENT AND LIMITS REQUIRED BY CONTRACT. CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: Earl Barrett P.O. Box 4748 Clearwater FL 33758 -4748 USA 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 t gA7YSr t9f. a.Q ./r'.4 fiA 0 �f1fA ACORD 25 (2014/01) 01988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Holder Identifier Certificate No : 570054216753 AGENCY CUSTOMER ID: 570000027366 LOC #: ADDITIONAL REMARKS SC Paae of AGENCY Aon Risk Services Northeast, Inc. NAMED INSURED Cellco Partnership POLICY NUMBER See Certificate Number: 570054216753 CARRIER See Certificate Number: 570054216753 NAIC CODE EFFECTIVE DATE: T1ONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance INSURER(S) AFFORDING COVERAGE NAIC # INSURER INSURER INSURER INSURER ADDITIONAL POLICIES If a policy below does not include limit information, refer to the corresponding policy on the ACORD certificate form for policy limits. INSR LTR TYPE OF INSURANCE ADDL INSR SUER wVD POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YYYY) POLICY EXPIRATION DATE (MM/DD /YYYY) LIMITS WORKERS COMPENSATION C N/A wc026035009 FL 06/30/2014 06/30/2015 B N/A wc026035011 MN 06/30/2014 06/30/2015 B N/A wc026035012 MA,MI,ND,OH,WA,WI,WV,WY 06/30/2014 06/30/2015 B N/A WCO26035006 IL KY NC NH UT VT 06/30/2014 06/30/2015 B N/A WCO26035007 AK AZ GA VA 06/30/2014 06/30/2015 B N/A wc026035008 N7 PA 06/30/2014 06/30/2015 B N/A WCO26035010 ME 06/30/2014 06/30/2015 ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved.