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CERTIFICATE OF LIABILITY INSURANCE (552)IPl'6402uOo2 ACO • RECEIVED APR 4 2014 CERTIFICATE OF LIABILITY INSURANWADMIN DATE(MMIDDIYYYY) 03/28/2014 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 1- 813 - 229 -8021 M. B. Wilson Co., Inc. 300 W. Platt St. Ste 200 Tampa, FL 33606 INSURED Pepper Contracting Services, Inc. 6920 Asphalt Avenue Tampa, FL 33614 CONTACT NAME: Diana Defreeuw PHONE (A/C, No, Ea): E -MAIL ADDRESS: INSURER A : INSURER B : INSURER C : INSURER D : INSURER E : INSURER F : ddefreeuw@mewilson.coam INSURER(S) AFFORDING COVERAGE LIBERTY MUT FIRE INS CO LIBERTY INS CORP BRIDGEFIELD EMPLOYERS INS CO (A C, No): NAIC N 11748 42404 10701 COVERAGES CERTIFICATE NUMBER: 39012191 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 SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ASR yrVQ POLICY NUMBER (MMIDDIYYYYI IMMIDDIYYYY) LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR GEN'L AGGREGATE LIMIT APPLIES PER. POLICY X ELT LOC TB2Z91460426014 01/01/14 01/01/15 EACH OCCURRENCE PREMISES (EaEoccu ence) MED EXP (Any one person) PERSONAL 8 ADV INJURY GENERAL AGGREGATE PRODUCTS - COMP /OP AGG $ 1,000,000 $ 300, 000 $ 10,000 $ 1,000,000 $ 2,000,000 $ 2,000, 000 $ A AUTOMOBILE LIABILITY X ANY AUTO I ALL OWNED : SCHEDULED , AUTOS AUTOS X X' NON -OWNED HIRED AUTOS AUTOS AS2Z91460426024 01/01/14 01/01/15 COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE (Per accident) $ 1,000,000 $ $ $ $ B X UMBRELLA LIAB X OCCUR EXCESS LIAB CLAIMS -MADE DED ' X - RETENTION $ 0 1TH7Z91460426034 01/01/1 01 /01 /15 EACH OCCURRENCE AGGREGATE $ 8,000,000 $ 8,000,000 $ C I WORKERS COMPENSATION ANDEMPLOYERS'LIABILITY YIN I ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N I A 083050524 04 /O1 /1+! 04/01/15 WC STATU- IOTH- X TORY LIMITS ER E.L. EACH ACCIDENT — E.L. DISEASE - EA EMPLOYEE E.L. DISEASE - POLICY LIMIT $ 500, 000 - $ 500, 000 $ 500, 000 I I I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Project: Ridge Road Widening (Broad Street to Moon Lake Road / Decubellis Raod) Bid No. IFB -DL -13 -004 Pasco County Board Of County Commissioners and City of Clearwater dba Clearwater Gas System are recognized as additional insured's with respect to General Liability when required by written contract. 30 day notice of cancellation, except 10 days for non - payment. CERTIFICATE HOLDER CANCELLATION City of Clearwater dba Clearwater Gas System Brian Langville, Operations Manager c/o 400 N. Myrtle Avenue Clearwater, FL 33775 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 � nn e.; �_ a ACORD 25 (2010/05) RD001 39012191 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ENV 11694 P52002 :0M2 - M. E. Wilson Co., Inc. 300 W. Platt St. Ste 200 Tampa, FL 33606 Electronic Service Requested RECEIVED APR 4 2014 GAS ADMIN 3 -DIGIT 337 11694 0.8502 AT 0.403 II'llllIIIlllIlllinli 11111I1 .IIIlll1'IIIIIII'lliull'III' City of Clearwater 34 dba Clearwater Gas System C/0 400 N. MYRTLE AVENUE CLEARWATER, FL 33755 -4433 This document was brought to you by CertificatesNow. - EBIX BPO If you have questions regarding the content of this document, please contact - the Producer /Agent listed on the certificate of insurance or the Insured listed on the notice of cancellation /reinstatement. - To find out how you can send and receive all of your certificates of insurance - either by email, high speed fax or standard mail, - email customercare @confirmnet.com, or visit our website at - www.confirmnet.com- cc: The data included in this notice and in the attached document is confidential to Ebix BPO and the party responsible for bringing you this information. Certificate Delivery by CertificatesNow - www.ConfirmNet.com - 877.669.8600 ENV 11694