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2014 ANNUAL STORMWATER IMPROVEMENTS - 14-0004-EN - CERTIFICATE OF LIABILITY INSURANCE
KEYST -1 OP ID: SB ACORO" �,�,.�= CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 11/20/2014 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 Fessler Agency - Clearwater 3165 N McMullen Booth Road G -2 Clearwater, FL 33761 -2020 Case J. Fessler, AAI, CIC CONTACT NAME: PHONE FAX (A/C. No, Eat): (A/C, No): E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : National Trust 20141 INSURED Keystone Excavators, Inc. 371 Scarlet Blvd. Oldsmar, FL 34677 INSURER B : FCCI Commercial Insurance Co. 33472 INSURER C : FCCI Insurance Company 10178 INSURER D : Allied World Assurance Co. $ 1,000,000 INSURER E : Phoenix Insurance Company 25623 INSURER F : COVERAGES CERTIFICATE 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 LTR TYPE OF INSURANCE ADDESUBR INSR WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP -' (MM /DD /YYYY) LIMITS A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X X GL000954836 T NOV2 5 2014 /� O Fp(; °pg� 2/01 /2014 J 12/01/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE 7 POLICY X LIMIT APPLIES PER: jE n LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS X SCHEDULED AUTOS NON -OWNED AUTOS X X p�q�rr-^ r- '�-`cce+Qak� L6:,��)r C'j. F :w,, CA00148526 wal Avid p4b14 12/01 /2015 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE JPER ACCIDENT) $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE UMB00098586 12/01/2014 12/01/2015 EACH OCCURRENCE $ 4,000,000 AGGREGATE $ 4,000,000 DED X RETENTION $ 10000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A X 60855 12/01/2014 12/01/2015 X WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 D E POLLUTION Equipment Floater 03090041 6603842B003 05/10/2014 12/01/2014 05/10/2015 12/01/2015 LIMITS 1,000,000 LIMITS 250,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space Is required) RE: 2014 Annual Stormwater Improvements Project #14- 0004 -EN/ City of Clearwater is included as additional insured on the General Liability per form CG2033; on the Auto Liability per form CAU001; Umbrella policy follows form. Waiver of Subrogation is included for the additional insured on the General Liability per form CGL004; on the Auto Liability *next page RTIFICATE HOLDER CANCELLATI 1 CITYCLE City of Clearwater 100 South Myrtle Ave., Clearwater, FL 33756 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 d, ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD NOTEPAD: • HOLDER CODE CITYCLE INSURED'S NAME Keystone Excavators, Inc. KEYST -1 PAGE 2 OP ID: SB Date 11/20/2014 per form CAU014; and blanket waiver applies on the Workers Compensation