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LIFT STATION 33 - 09-0003-UT & LIFT STATION 42 - 10-0051-UT - REHABILITATION PROJECTS - CERTIFICATE OF LIABILITY INSURANCE1---P5240028W2 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 03/24/2014 • 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 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 N. E. Wilson Co., Inc. 300 W. Platt St. Ste 200 Tampa, FL 33606 INSURED TLC Diversified, Inc. 2719 17th Street East Palmetto, FL 34221 1- 813 - 229 -8021 CONTACT Diana Defreeuw AE: PHONE 813- 229 -8021 FAX (A/C, No, EA: (A/C, No): E-MAIL ADDRESS: ddefreeuw@mewilson.com INSURER(S) AFFORDING COVERAGE INSURER A: WESTFIELD INS CO INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : FCCI INS CO NAIC 24112 10178 COVERAGES CERTIFICATE NUMBER: 38912922 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! ADDL'SI/BR POLICY EFF POLICY EXP I LTR TYPE OF INSURANCE JNS WVR POLICY NUMBER IMM /DD/YYYY) (M ; MIDDIYYVY) LIMITS R. A GENERAL X I X X 1 GEN'L LIABILITY COMMERCIAL GENERAL LIABILITY • CLAIMS -MADE , X OCCUR Contractual Liability $500 Prop Dmg Ded AGGREGATE LIMIT APPLIES PER: POLICY X .. JE a % LOC ITRA3972460 �[� ° 3 ��'{ p I 04/01/14 04/01/15',. EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500,000 1 MED EXP (Any one person) i $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP/OP AGG ', $ 2,000,000 $ A IX AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED 1 AUTOS . AUTOS NON -OWNED X HIRED AUTOS ! X . AUTOS ACCORDANCE WITH THE POLICY PROVISIONS. !TRA3972460 04/01/14 04/01/151 COMBINED SINGLE LIMIT I (Ea accident) 1 $ 1,000,000 BODILY INJURY (Per person) '' $ BODILY INJURY (Per accident) ' $ ' I PROPERTY DAMAGE 'I (Per accident) $ A X I, UMBRELLALIAB 1 EXCESS LIAB DED X RETENT I X OCCUR '.I CLAIMS -MADE' ON $ 0 USA ,TRA3972460 04/01/14 04/01/15'. EACH OCCURRENCE AGGREGATE $ 5,000,000 $ 5,000,000 $ B I WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N'� OFFICER/MEMBER EXCLUDED? N :.. (Mandatory In NH) '', It yes, describe under DESCRIPTION OF OPERATIONS below N I A 001WC13A61661 ! 04/01/14 1 WC STATU- I, OTH - , '� 04/0l/15' X TORY LIMITS ER ; E.L. EACH ACCIDENT $ 500, 000 I E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500, 000 A !Installation Floater ITRA3972460 I 04/01/14 04/01/15 $1,000 Ded 1,000,000 ! iTransit & Storage: Included Deductible: 1,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) Certificate Holder Listed as Additional Insured Lift Station 33 (09- 0003 -UT) and Lift Station 42 (10- 0051 -UT) Rehabilitation Projects TLC Job # 13 -12 -01 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010105) CVO1 38912922 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. P.O. Box 4748 learwater, FL 33758 -4748 AUTHORIZED REPRESENTATIVE ( --��� " "",��� i�4(c (lam USA a4 ACORD 25 (2010105) CVO1 38912922 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD