CERTIFICATE OF LIABILITY INSURANCE (650)i�� JGREZTR-01 LEWISC
DATE (MM/DD/YYYY)
'`��R°� �` CERTIFICATE OF LIABILITY INSURANCE 5/27/2015
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
Insurance Office of America, Inc.
4915 West Cypress Street
Tamoa. FL 33607
INSURED
J Grez Transport, Inc.
6001 N. 50th Street
Tampa, FL 33610
hy Lewis
13) 637-8877
INSURER(S) AFFORDING COVERAGE
Southern-Owners Insurance Com
iNSUReR s: Canal Insurance Coi
INSURER C : EV8f1StOf1 I11SU�8�iC@
�NSUReR o: Florida Citrus, Business 8� Industries Fund
�NSUReR e: Hartford Fire Insurance Company
INSURER F :
637-8484
NAIC #
10190
10464
NA
19682
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 POL�CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAfMS.
INSR rypE OF INSURANCE POLICY NUMBER MM/DD/YEYYY MM/ DY/YYW LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ �,OOO,OO
CLAIMS-MADE � OCCUR X 20115108 �s/��/Z�15 �s/��/2��6 pREMISES Eaoccurrence $ 50,��
MED EXP (Any one person) $ 5,�0
PERSONAL 8 ADV INJURY $ i3OOO,OO
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ Z,OOO,OO
X POLICY � PR� � LOC PRODUCTS - COMP/OP AGG $ Z,OOO,OO
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT g 'I OOO,OO
Ea accident �
B ANY AUTO X PIA07705701 06/02/2015 �s/�Z/Z�� s BODILY INJURY (Per person) $
ALL OWNED X SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
PIP $ 10,00
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ S,OOO,OO
C X EXCESSLIAB CLAIMS-MADE 83645912 �s/�Z/Z�iS �6/�Z/2��6 AGGREGATE $ 5,����0�
DED RETENTION $ $
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS' IIABILITY STATUTE ER
D ANYPROPRIETOR/PARTNER/EXECUTIVE Y�N 10654214 03/01/2015 03/01/2016 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 OF OPERA710NS below E.L. DISEASE - POLICY LIMIT $ �,OOO,OO
B Trailer Interchange PIA07705701 O6/02/2015 06/02/2016 Ded. a1,000 30,00
E Motor Truck Cargo 21 MS2P8230 05H 3/2015 O6/02/2016 Ded. 51,000 100,00
DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (ACORD 101, Addltional Remarka Schetlule, may be attached if more space is required)
Job Loc: Clearwater Solid Waste, 1701 N. Hercules Ave., Clearwater, FL 33765
City of Clearwater is an additional insured with respects to all policies except workers compensation. Coverage is written on a primary and non-contributory
basis. 30 days notice of cancellation with 10 days notice due to non-payment of premium in accordance with policy provisions.
CERTIFICATE HOLDER
City of Clearwater
Attn: Purchasing Department
ITB �t43-15
PO Box 4748
ACORD 25 (2014101)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WiLL BE DELIVERED IN
ACCORDANCE WITH THE POIICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
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O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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