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CERTIFICATE OF LIABILITY INSURANCE (615)�„t;-:� � . �"1 KCPETRO-01 JSMITH ACORO� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DD/YYYY) � 5/4/2015 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 dces not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Joanne Smith, CIC Cecil W. Powell & Company PHONE (904) 353-3181 ac No :(904) 353-5722 219 N. Newnan Street �vc No �c : Jacksonville, FL 32202 E-MAIL nnoRess: Jsmith[a�cwpowellins.com INSURED KC Petroleum Inc P O Box 60742 Jacksonville, FL 32236 INSURER(S) AFFORDING COVERAGE �r,suReRn:Colony Insurance Company �NSUReRS:Owners Insurance Co iNSUReR c: FCCI Insurance Company INSURER D : INSURER F : NAIC # 10178 COVERAGES CERTIFICATE NUMBER: 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. N0TIMTHSTANDING 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. I�TR TYPE OF INSURANCE POLICY NUMBER MM DDY/YYW MM/DDY/YYYY LIMITS A X COMMERCIALGENERALLIABILITY EACHOCCURRENCE $ �,OOO,OO CLAIMS-MADE � OCCUrt EPK301696 09H1/2014 09N1/2015 pREMISES Eaoccurrence $ 50,00 MED EXP (My one person) $ 5,�� PERSONAL & ADV INJURY $ 'I,OOO,OO GEN'LAGGREGATELIMITAPPLIESPER: GENERALAGGREGATE $ Z,OOO,OO POLICY � jE � � LOC PRODUCTS - COMP/OP AGG $ Z,OOO,OO OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Eaaccident $ 1,000,00 B X ANY AUTO 4203213901 03/11/2015 03/11/2016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ H2OOO,OO /� X EXCESSLIAB CLAIMS-MADE EXC301697 �9/i�/20i4 09/11/2015 AGGREGATE $ $,��,�0 DED RETENTION $ $ WORKERS COMPENSATION X PER OTH- AND EMPLOYERS' LIABILITY STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N 001 WC15A42788 05/O6/2015 05/06/2016 E.L. EACH ACCIDENT $ 'I,OOO,OO OFFICER/MEMBER EXCLUDED? � N � A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ �,OOO,OO If yes, describe under DESCRIPTlON OF QPERAT!ONS trebw E.L. DISEASE - POLICY LIMIT $ ��OOO�OO A Pollution Liability EPK301696 09/11/2014 09N1/2015 Each Claim 1,000,00 A Claims Made Form EPK301696 09/11/2014 09/11/2015 9/11/2000 retro date DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CONCFI I OTIAN City of Clearwater 100 South Myrtle Ave Clearwater, FL 33756 ACORD 25 (2014/01) 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 ,��w�.,��. O 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD '�� KCPETRO-01 JSMITH A�oRO� CERTIFICATE OF LIABiLITY INSURANCE DATE�MM/DD/YYYY) 3/6/2015 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 certifcate 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 dces not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAMEACT Joanne Smith� C.�C. Cecil W. Powell 8 Company PHONE 904 35 ac No :(904) 353-5722 219 N. Newnan Street ac No exc :� ) 3-3181 Jacksonville, FL 32202 qDOR�ess: Jsmith cwpowellins.com INSURER�S) AFFORDING COVERAGE NAIC # INSURED KC Petroleum Inc P O Box 60742 Jacksonville, FL 32236 INSURER A: COIO�I�/ Ir1SU�8fiC@ CO� INSURER B :OW�I@I'S Ir1SU�8(IC@ CO iNSUReR c: FCCI Insurance Comp INSURER D : INSURER E : 10178 COVERAGES CERTIFICATE NUMBER: 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. NOTIMTHSTANDING 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 q g LTR TYPE OF INSURANCE POLICY NUMBER MM/DDY� MM/DDY� LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 'I,OOO,OO CLAIMS-MADE � OCCUR EPK301696 09/11/2014 09N1/2015 pREMISES Eaxcurrence $ 50,00 MED EXP (My one person) $ rJ,�O � PERSONAL 8 ADV INJURY $ 'I,OOO�OO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z�OOO,OO POLICY � �ER� � LOC PRODUCTS-COMP/OPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY Ea acB.ciiCentSINGLE LIMIT $ �,OOO,OO B X ANY AUTO 4203213901 03/11/2015 03/11/2016 BODILY INJURY (Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS AONO-0WNED PROPERTY DAMAGE $ Per accident $ UMBRELLA LIAB X OCCUR /.� X EXCESS LIAB CLAIMSaNADE EXC301697 �9/i i/ZOi4 09/11/2015 �CH OCCURRENCE $ $��00 AGGREGATE $ $,OOO,OO DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y � N X STATUTE ERH C ANYPROPRIETOR/PARTNER/EXECUTIVE 001WC14A42788 05/O6/2014 05/O6/2015 E.L.EACHACCIDENT $ 'I�OOO,OO OFFICER/MEMBER EXCLUDED? � N � A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ �,OOO�OO If yes, describe under DESCRIPTION OP OPERATIONS t�+low E.L. DISEASE - POLICY LIMIT $ i3OOO,OO A Pollution Liability EPK301696 09/11/2014 09/11/2015 Each Claim 1,000,00 A Claims Made Form EPK301696 09/17/2014 09N1/2015 9/11/2000 retro date DESCRIP710N OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schetlule, may be attachetl if more space is required) CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 South Myrtle Ave Clearwater, FL 33756 ACORD 25 (2014/01) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORI2ED REPRESENTATIVE �� O 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD