CERTIFICATE OF LIABILITY INSURANCE (3)_ __ __ _ __ _
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� A� � CERTIFICATE OF LIABILITY INSURANCE 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 ceAificate dces not confer rights to the
certificate hoider in lieu of such endorsement(s�.
PRODUCER 1-813-229-8021 CONTACT Diana Defreeuw
NAME:
M. B. Wilson Co., Inc. PHONE
�ac, No, Exy: 813-229-8021 {ac, r+o�:
300 W. Platt St. pooR�ess: ddefreeuw@mewilson.com
sce 200
Tampa, FL 33606 INSURER�S) AFFORDING COVERAGE � NAIC X
INSURER A:�%STFIELD INS CO ' 24112
INSURED INSURERe: FCCI INS CO 110178
TLC Diveraified, Inc.
INSURER C :
2719 17th Stieet S88t INSURERD:
INSURER E : �I
Palmetto, FL 34221 ',
INSURER F :
COVERAGES CERTIFICATE NUMBER: 3e9i2843 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 SUBR'� � ���. POLICY EFF � POLICY EXP ��� LIMITS
�� TYPE OF INSURANCE POLICY NUMBER �'�. MMIDDIYYYY MMIDDIYYYY ��
1► 'I GENERnLL1ABILRY i ' '��,TRA3972460 i 04/Ol/1� 04/Ol/15 EACHOCCURRENCE $ 1,000,000
I X �. �, I ''�, ��, DAMAGE TO RENTED ��, $ 500, 000
i COMMERCIAL GENERAL LIABILITY �. I ' �, �, ' PREMISES (Ea occurtence) , .
I I ,
�� � '��, CLAIMS-MADE I. X'�, OCCUR - � I �li ��, I MED EXP (Any one person) .. $ 10, 000
,$ I COIItL'8Ctu31 Llablllty �� �. �A i� PERSONAL 8 ADV INJURY �'., $ l, 000, 000
I X�'i $500 Prop Dwg Ded �,I ' li APR 0 3 2� �t II % GENERAL AGGREGAiE $ 2. 000, 000
I�I� GEN'L AGGREGATE LIMIT APPLIES PER: '��. I � � I�, pRODUCTS - COMP/OP AGG '�� $ 2, 000, 000
�'� �' POUCY i 8 ' PRO' �. X �, LOC �' �� I � ' � ' $
A'� AUTOMOBILEl1ABiLITY TRA3972d60 �i 4/Ol/14� 04/Ol/151. COMBINEDSINGLELIMIT � 1,000,000
, . . ��, {Ea accident) , $
I� X �I ANY AUTO �I' ' , � � BODILY INJURY (Per person) �, $
�� �, ALLOWNED �' SCHEDULED I � I
. i i I�I � ���, BODILY INJURY (Per accident)'. $
' '�i AUTOS � �� AUTOS '�. �; �
��� X���. HIREDAUTOS I� X I���.., AUTOSWNED �I, I, I I� ���''.. {Pe�accidentDAMAGE :$
, .� . .. � I � ', �� $
A',�( , UMBRELLALIABI x i OCCUR ITRA3972460 04/Ol/l4 04/Ol/151� EACHOCCURRENCE $ 5,000,000
�', �'�: EXCESS LIAB '� I CLAIMS-MADE �. ���.. I, I� � I AGGREGATE '$ 5, 000, 000
i ,� . ,� �i ,, ��. . �
�� � DED X ' RETENTION $ � � �' � ' $
8! WORKERSCOMPENSATION ' � 04/O1/15. X WCSTATU- ��, �OTH-'�
i ANDEMPLOYERS'LIABILITY YIN II '�.001WC13A61661 04/Ol/14 TORYLIMIT$I � ER '�
'�, ANY PROPRIETORIPARTNERIEXECUTIVE ❑�,, N � A I �'� �I �i '�, E.L EACH ACCIDENT $ 500, 000
'��. OFFlCER/MEMBER EXCLUDED? N . �. �
'(Nandatory in NH) ��, ��� '� E.L. DISEASE - EA EMPLOYEE $ 500, 000
' II yes, describe under ' �. , li, �� 500 � 000
�. DESCRIPTION OF OPERATIONS below ' � E.L. DISEASE - POLICY UMIT �$
A;Inetallation Floater TR73972460 04/O1/l�q 04/O1/15 $1,000 Ded 1,000,000
� �, �I i Traneit & Storage: Included
' ', � ' ' 'Deductible: 1.000
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attach ACORD 707, Add'Rional Ramarks Sehadule, if more spaco fs roquired)
City of Clearwater is included as an additional insured se respects general liability
Marshall St. � East APCF Chlorine Gas & Sulfur Dioxide Gas Conversion Project (07-0021-UT)
ty of Cleaxwater
P.O. Box 4748
Cleaxwater, FL 33758-4748
ACORD 25 (2010/05)
CVOi
38912843
SNOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELIED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZEO REPRESENTATIVE
� �� ����
USA
O 1988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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