CERTIFICATE OF LIABILITY INSURANCE (614)'``�� `� CERTIFICATE OF LIABILITY INSURANCE I DATE(MMIDD/YYYY)
3/11/2015
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 NAMEA T DOIIIIB Griffiths
Guy Hurley Blaser and Heuer, LLC PHONE (248)519-1439 F�
N xt : p� � ; (248) 519-1401
1080 Kirts Blvd., Suite 500 E'MA`�� d riffiths@ hbh.com
ADDRESS: g �J
T=oY MI 48084
INSURED
Kamminga & Roodvoets, Inc.
3435 Broadmoor S.E.
Grand Rapids MI 49512
INSURER A
E:
Mutual
COVERAGE NAIC #
e Co. 19488
6 Cas Co. 25674
VVYCRAL7C�7 l,tKlltll:Alt NUMt3ER:lb-16 �t Lines Ut� AI 2M 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.
INTR 7yPE OF INSURANCE �►DDL SUBR POLICY EFF POUCY EXP
POLICY NUMBER M DD/YYYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, 000 , 000
A CLAIMS-MADE X� OCCUR DAMAGE TO RENTED 300 , 000
PREMISES Ea occurrence $
X CPP 2091818 4/1/2015 4/1/2016 MED EXP(Anyoneperson) $ 5,000
RECEiti/ED
PERSONAL&ADVINJURY $ 1,000�000
GEN'L AGGREGATE LIMIT APPLIES PER: C ITY � F C L. r A R W T E R GENERAL AGGREGATE $ 2, 000 , 000
POLICY � �E � � LOC
P�AR �- 9 201� PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER: g
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
R�SK/V�A�H(J�� (�T Eaaccident $ 1,000,000
A X ANY AUTO BODILY INJURY (Per person) $
ALLOWNED SCHEDULED Cp, 2091812 9173 4/1/2015 4/1/2016 BODILYINJURY Peraccident $
AUTOS AUTOS i )
X HIRED AUTOS X NON-0WNED PROPERTY DAMAGE
AUTOS Per accident $
PIP-Basic $
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 2 000 000
B EXCESS LIAB CLAIMS-MADE AGGREGATE
S 2 000 000
DED RETENTION$ 2UP-15S30627 4/1/2015 4/1/2016 $
WORKERS COMPENSATION X PER TH-
AND EMPLOYERS' LIABILITY Y� N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 5O0 OOO
OFFICER/MEMBER EXCLUDED? � N � A
C (Mandatory i� NH) WC 2091813 4/1/2015 4/1/2016 E.L. DISEASE - EA EMPLOYE $ 500 000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500 000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 701, Additional Remarks Schedule, may be atfached if more space is required)
Project: 51501 Countryside Manhole Rehabilitation. The City of Clearwater is an Additional Insured for
General Liability when required by mritten contract. Waiver of Subrogation applies in favor of the City
of Clearwater for General Liability, Automobile Liability and Workers Compensation when required by
written contract. 30 Day Notice of Cancellation (Except Non-Payment of Premium) applies in favor of the
City of Clearwater or General Liability, Automobile Liability and Workers Compensation when required by
written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
100 S. Myrtle Ave ., 3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater„ E'L 33756
AUTHORIZED REPRESENTATIVE
Mark Madden/WEAL �'`{�"`r-- -� ?' - � - -
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (2o�ao�)
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