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CLEARWATER CONCENTRATE INJECTION DEEP WELL PROJECT PHASE 2 - 09-0044-UT - CERTIFICATE OF LIABILITY INSURANCE (2)F5260020002 S ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 12/30/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS iiCERTIFICATE 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 M. E. Wilson Co., Inc. 300 W. Platt St. Ste 200 Tampa, FL 33606 INSURED Applied Drilling Engineering, Inc. 10014 N. Dale Mabry Suite 205 Tampa, FL 33618 1 -813- 229 -8021 CONTACT NAME: Kristen Willis PHONE FAX WC, No, Ertl:... (A/C, Nod: E-MAIL DRE kWi11i8L�meWi180n. COm ADDRESS:._. _.. ___... INSURERS) AFFORDING COVERAGE INSURER A: Westfield IDS Co INSURER B : Zenith Ins Co INSURER C : INSURER D : INSURER E : INSURER F : NAIC S 24112 13269 COVERAGES CERTIFICATE NUMBER: 37803170 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. INSR' TYPE OF INSURANCE ADDL. LTR INSR SUBR WVD LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY THE INSURANCE AFFORDED BY LIMITS SHOWN MAY HAVE BEEN POLICY NUMBER ISSUED TO THE INSURED CONTRACT OR OTHER THE POLICIES DESCRIBED REDUCED BY PAID CLAIMS. POLICY EFF i POLICY EXP (MMIDD/YYYY) I (MMIDD/YYYYI NAMED ADOVE FOR THE POLICY PERIOD DOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, _- - -- LIMITS A GENERAL X X GEN'L -- - LIABILITY C OMMERCIA COMMERCIAL GENERAL LIABILITY ii CLAIMS -MADE X OCCUR $500 ded - prop dam AGGREGATE LIMIT APPLIES PER: X '. PRO - POLICY II T I LOC TRA3571467 +/�' JAN 1 3 ,._ 01/01/14 01 /01 /15 �� .r r •r 2014 , EACH OCCURRENCE DAMAGE TO RENTED PREMISES (Ea occurrence) MED EXP (Any one person) PERSONAL& ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP /OP AGG _... $ 1,000,000 $ 500, 000 $ 10, 000 $ 1,000,000 $ 2,000,000 $ 2,000,000 $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED I AUTOS ; g HIRED ; X SCHEDULED AUTOS NON -OWNED AUTOS TRA3571467 01/01:J1 01/01/15 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) - BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) _._. PIP $_ 1,000,000 $ - $ $ $ 10,000 A X UMBRELLA LIAB X OCCUR EXCESS LIAB 1 I CLAIMS -MADE DED i I RETENTION $ ! TRA3571467 O1 /01 /l 01/01/15 �% EACH OCCURRENCE AGGREGATE $ 5,000,000. $ 5, 000, 000. $ B AND EMPLOYERSELIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) - If yes, describe under DESCRIPTION OF OPERATIONS below N / A Z068841607 O1 /Ol /1 O1 /Ol /15 4 i WC STATUS I 10TH- XITORYLIMITSI ; ER E L EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E L DISEASE - POLICY LIMIT $ 1,000,000 _ _... $ 1,000,000 $ 1, 000, 000 A A Leased / Rented Equipment Installation Floater & Builder's Risk TRA3571467 TRA3571467 01 /01 /14 01/01/15 Leased /Rented Limit175,000 01/01/14 01/01/15 Catastrophe Limit 180,000 1 Jobsite Limit 25,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Project: Clearwater Concentrate Injection Deep Well Project Phase II Project #: 09- 0044UT CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 South Myrtle Avenue 41110 Suite 220 Clearwater, FL 33756 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 ACORD 25 (2010/05) KDOO1 37803170 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD