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CERTIFICATE OF LIABILITY INSURANCE (351)ACO CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 6/29/2015 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 Wallace, Welch & Willingham P.O. Box 33020 St. Petersburg FL 33733 NAME: Weyman Willingham PHONE 727 - 522 -7777 (A/C, No Fet)• E-MAIL SS: certificates @w3ins.com FAX 727 - 521 -2902 (A/C, No): INSURER(S) AFFORDING COVERAGE NAIC # INSURED Cumbey & Fair Inc 2463 Enterprise Rd Clearwater FL 33763 CUM &F -1 INSURER A :Valley Forge Insurance Co. /CNA INSURER B:Nat'I Fire Ins Co of Hartford 20508 20478 INSURER c :Transportation Ins. Co. 20494 INSURER D : Bridgefield Employers Ins. Co. 10701 INSURER E :Admiral Insurance Company INSURER F : COVERAGE • 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DDIYYYY) POLICY EXP (MM/DDIYYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY C2086949437 3/16/2015 3/16/2016 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $100,000 GEN'L MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 AGGREGATE POLICY OTHER: X LIMIT APPLIES PER: LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ B AUTOMOBILE X LIABILITY ANY AUTO AAUTOS�ED HIRED AUTOS — SCHEDULED NON -OWNED AUTOS C2088208783 3/16/2015 3/16/2016 CUMUINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ C X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE C2086949471 3/16/2015 3/16/2016 EACH OCCURRENCE $2,000,000 AGGREGATE $2,000,000 DED X RETENTION$0 $ D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N /A 0830543680 3/16/2015 3/16/2016 X STATUTE X SRH U.S.L. H. E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 E Professional Liab Claims Made Retro Date 2/19/2000 E000002866101 4/9/2015 4/9/2016 Each claim $1,000,000 Aggregate $1,000,000 Deductible $25,000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached it more space is required) City of Clearwater is Additional Insured on a primary and non contributory basis with respect to General Liability if required by written contract. City of Clearwater is Additional Insured with respect to Auto Liability per Auto Coverage Form and on the Excess Policy subject to the underlying policy terms and conditions. A Waiver of Subrogation in favor of City of Clearwater applies to General Liability, Auto Liability and Workers Compensation if required by written contract. TIFICATE HOLDER CANCELLATION City of Clearwater Engineering, RFQ #34 -15 P.O. Box 4748 Clearwater FL 33758 -4748 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 ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD cNA G- 17957 -H (Ed. 01/13) BLANKET ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - WITH PRODUCTS- COMPLETED OPERATIONS COVERAGE - LIMITED LIABILITY It is understood and agreed that this endorsement amends the COMMERCIAL GENERAL LIABILITY COVERAGE PART as follows: SCHEDULE (OPTIONAL) Name of Addition! Insured Persons Or Organizations (As required by "written contract per Paragraph A. below.) Locations of Covered Operations (As per the "written contract," provided the location is within the' coverage territory' of this Coverage Part.) A. Section II - Who Is An Insured Is amended to include as an additional Insured: 1. Any person or organization whom you are required by 'written contract' to add as an additional insured on this Coverage Part; and 2. The particular person or organization, if any, scheduled above. 0 B. The insurance provided to the additional insured is limited as follows: ° 1. The person or organization is an additional insured only with respect to liability for `bodily Injury,' 'property damage,` or 'personal and advertising injury' and only to the extent caused by: a. Your negligent acts or omissions, or the negligent acts or omissions of those acting on your behalf, In the performance of your ongoing operations specified in the 'written contract'; or 2 b. 'Your work' that is specified in the 'written contract' but only for 'bodily injury" or 'property damage' Included n in the 'products- completed operations hazard,' and only If: (1) The 'written contract' requires you to provide the additional insured such coverage; and (2) This Coverage Part provides such coverage. s 2. We will not provide the additional insured any broader coverage or any higher limit of Insurance than: a. The maximum permitted by law; b. Required by the 'written contract'; c.. Described In B.1. above; or ggM d. Afforded to you under this policy, whichever is less. 3. Notwithstanding anything to the contrary in Condition 4. Other Insurance (Section IV), this insurance is excess of a all other insurance available to the additional insured whether on a primary, excess, contingent or any other basis. But if required by the 'written contract' to be primary and non - contributory, this insurance will be primary and non- contributory relative to insurance on which the additional insured Is a Named Insured. �:— 4. The insurance provided to the additional insured does not apply to 'bodily injury,' 'property damage,' or 'personal z and advertising injury" arising out of: G- 17957 -H (01/13) Page 1 of 2 Copyright, CNA All Rights Reserved. G- 17957 -H (Ed. 01/13) a. Acts or omissions of the additional insured, or of anyone, other than you, acting on the additional insured's behalf. b. The rendering of, or the failure to render, any professional architectural, engineering, or surveying services, including: (1) The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; and (2) Supervisory, inspection, architectural or engineering activities; or c. Any premises or work for which the additional insured is specifically listed as an additional insured on another endorsement attached to this Coverage Part. C. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS is amended as follows: 1. The Duties In The Event of Occurrence, Offense, Claim or Suit condition is amended to add the following additional conditions applicable to the additional insured: An additional insured under this endorsement will as soon as practicable: (1) Give us written notice of an 'occurrence' or an offense which may result in a claim or 'suit' under this insurance, and of any claim or 'suit that does result; (2) Except as provided in Paragraph B.3 of this endorsement, agree to make available any other insurance the additional insured has for a loss we cover under this Coverage Part; (3) Send us copies of all legal papers received, and otherwise cooperate with us in the investigation, defense, or settlement of the claim or 'suit; and (4) Tender the defense and indemnity of any claim or 'suit' to any other insurer or self insurer whose policy or program applies to a loss we cover under this Coverage Part. But If the 'written contract requires this insurance to be primary and non - contributory, this provision (4) does not apply to insurance on which the additional insured is a Named Insured. We have no duty to defend or indemnify an additional insured under this endorsement until we receive from the additional insured written notice of a claim or 'suit.' D. Only for the purpose of the insurance provided by this endorsement, SECTION V — DEFINITIONS is amended to add the following definition: 'Written contract' means a written contract or written agreement that requires you to make a person or organization an additional insured on this Coverage Part, provided the contract or agreement: 1. is currently in effect or becomes effective during the term of this policy; and 2. Was executed prior to: a. The 'bodily injury' or 'property damage "; or b. The offense that caused the 'personal and advertising injury' for which the additional insured seeks coverage under this Coverage Part. All other terms and conditions of the Policy remain unchanged. G- 17957 -H (01/13) Page 2 of 2 Copyright, CNA All RUghts Reserved. POLICY NO NA= C 2086949437 IN80RED NANA AND ADDAZA8 CUMEEY & FAIR INC 2463 ENTERPRISE RD CLEARWATER `FL 33763 POLICY CHANGES MINE=c0244 This Change Endorsement Changes the Policy. Please read it carefully. This Change Endorsement is a part of your Policy and takes effect on the effective date of your Policy, unless another effective date is ahem. CG 24 04 SCHEDULE Name of Person or Organization: Any person or organization with whom you have agreed in writing in a contract or agreement to waive any right of recovery against such person or organization, but only if the contract or agreement: 1. Is in effect or becomes effective during the term of this policy; and 2. Was executed prior to loss. he.,w.a tea. Chemina the Board G- 56015 -8 (ED. 11/91) 50020008320882087838552 CNA 9- 23186 -A (Ed. 05/89) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER RIGHTS OF RECOVERY AGAINST OTHERS This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM GARAGE COVERAGE FORM TRUCKERS COVERAGE FORM SCHEDULE Name of Person or Organization: ANY PERSON OR ORGANIZATION FOR WHOM OR WHICH YOU ARE REQUIRED BY WRITTEN CONTRACT OR AGREEMENT TO OBTAIN THIS WAIVER FROM US. YOU MUST AGREE TO THAT REQUIREMENT PRIOR TO LOSS. (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) We waive any right of recovery we may have against the person or organization shown in the Schedule because of payments we make for the injury or damage. This injury or 9- 23186 -A (Ed. 05/89) damage must arise out of your activities under a contract with that person or organization. The waiver applies only to the person or organization shown in the Schedule. Page 1 of 1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT WC 00 03 13 (Ed. 4-84) We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not enforce our right against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work under a written contract that requires you to obtain this agreement from us.) This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule. Schedule *Blanket Waiver of Subrogation Applies* This endorsement changes the policy to which It is attached and is effective on the date issued unless otherwise stated. Date Prepared: March 16, 2015 Carrier: Bridgefield Employers Insurance Company Effective Date of Endorsement: March 16, 2015 Policy Number: 830 -54368 Countersigned by Insured: Cumbey & Fair, Inc. WC 00 03 13 (Ed. 4 -84) "Includes copyright material of the National Council on Compensation Insurance, Inc. used with Its permission. Copyright 1984 NCCI"