CERTIFICATE OF LIABILITY INSURANCE (4)____ _.__ __
P52(NR12ri1M12 �
�� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVEIY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OP INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER�S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERT�FICATE 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).
PROOUCER 1-813-229-8021 CONiACT Di8II8 Defreeuw
NAME:
M. B. Wilson Co., Inc.
jacNr u. �.p: 813-229-8021 , jac, No�:
300 W. Platt St. E-MAII ddefreeuw@mewilson.com
Ste 200 ADDRESS; ,
Tampa, FL 33606 INSURER(S) AFFORDING COVERAGE � NAIC •
INSURED
TLC Diveraified, Inc.
2719 17th Street Bast
Palmetto, FL 36221
INSURERA: �STFIELD INS CO
INSURER B: FCCI INS CO
INSURER C :
INSURER D :
INSURER E :
INSURER F :
24112
10178
COVERAGES CERTIFICATE NUMBER: 3e9izaa2 REVISION NUMBER:
THIS IS TO CERTIFY THAT TNE POLICIES OF INSURANCE LtSTED 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 NEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE '�DL SUBR��. pOLICY NUMBER � MMIDDIYYYY . MMIDDIYYYY � LIMITS
LTR
1► GENERALLWBIUtt I iTRA3972660 � Od/Ol/1�} 04/Ol/15' EACHOCCURRENCE g 1,000,000
��� g'��. COMMERCIAL GENERAL LIABIUTY ' �I �I ! I '� DAMAGE TO RENTED 500, 000
,, i � ''�. pREMISES (Ea cecunence) ; $
; I ( Y P ) 10.000
'� � CLAIMS-MADE X���. OCCUR � ��, I ��� MED EXP An one erson '. $
% � Contractual Liability i ' 1,000,000
�. � i '�. PERSONAL 8 ADV INJURY �. $
�%�!i $500 PrOy I1mg Ded , II I ��� ���: GENERAL AGGREGATE �$ 2, 000, 000
�, GEN'L AGGREGATE LIMIT APPLIES PER. . �. .� '� �� PRODUCTS - COMG/OP AGG �.. $ 2. 000, 000
. ,, POLIGY '. x , PRO- X i LOC I. ' ', . '�,.. $
a�. AUTOMOBILELIABIUTY �iTRA3972460 O /Ol lfi 04/Ol/15 COMBINEDSINGLEIIMIT '� 1,000,000
� �� � ! (Ea acddenq �i $
��� X I qNY AUTO - � �I, P , ��� BODILY INJURY (Per person) '�. S
�
� �, ALL OWNED I SCHEDULED .� , �,, I - ��; BODILY INJURY (Per accidenQ �'� $
, ���, AUTOS I �, AUTOS � � �
, NON-OWNED ��� '�, �'�� �� j PROPERTY DAMAGE
' X �'�� HIRED AUTOS � X �: AUTOS ' ! ', ', ��, (Per accident) �, $
�. ��' �� � �, I ��.' ' �'�' ��. $
� Ig I UMBRELLALIAB I x, OCCUR TRA3972460 ', 04/O1/1� 04/O1/15, EACHOCCURRENCE $ 5,000,000
� j � �� i i ,
��, �, EXCESS LIAB � �'�� CLAIMS MADE �� �'il i �, , �, AGGREGATE $ 5, 000, 000
�� DED X � RETENTION 3 � ' ! �� ' ��� $
B� WORKERS COMPENSATION �' � OO1WC13A61661 WC STATU- '� OTH- �,
�� ANDEMPLOYERS'LIA8ILITY ! i 04/Ol/1� 04/Ol/15' X TORYLIMITS��. ���. ER ,
Y I N �. �. Ii �..
'�. ANY PROPRIETORIPARTNER/EXECUTIVE i � � '� E.L EACH ACCIDENT ��. j 500, 000
'� OFFICER/MEMBER EXCLUDED? N� � N � A �� I � �! '� '
�' (Maodatory in NH) '�. � �.. E.L. DISEASE - EA EMPLOVEE $ 500, 000
�� If yes, describe under . ' �.
'�� DESCRIPTION OF OPERATIONS below � �� � '�� EL. DISEASE - POLICV LIMIT �$ 500, 000
1► ',Inatallation Floater , j IITRA3972460 i Od/O1/lq 04/O1/15 $1,000 Ded 1,000,000
i
,' j i ', 'Tranait 8 Storage: Zncluded
' , Deductible: 1,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES �Attach ACORD 107, AddRional Ramarks Schodule, if mora spaca {s required)
City of Clearwater ie included as an additional ineured as reeyects qeneral liability
Lift Station �41 Rehabilitation Project (PO#ST 106423)
TE HOLDER
City of Clearwater
P.O. Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2010105)
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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
� �� ����
USA
O 1988-2010 ACORD CORPORATION. Ali rights reserved.
The ACORD name and logo are registered marks of ACORD
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