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NEW PARKS AND BEAUTIFICATION BEACH MAINTENANCE BUILDING AT MANDALAY PARK - 08-0064-PR-A - CERTIFICATE OF LIABILITY INSURANCEClient#: 13862 GROSZCON ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD /YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 1 10/0112015 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 CONTACT NAME: Bouchard Insurance (CLW) PHONE 727 447 -6481 FAX 727 449 -1267 A/C, No, Ext : (A/C, No): 101 N Starcrest Dr. E-MAIL Y ADDRESS: cicertsftm ers bouchardinsurance.com Clearwater, FL 33765 091251201 EACH OCCURRENCE $1,000,000 INSURER(S) AFFORDING COVERAGE NAIC # 727 447 -6481 INSURERA: Auto - Owners Insurance Company 18988 INSURED INSURER B: Southern Owners Insurance Co 10190 Grosz Construction CLAIMS -MADE Fx_] OCCUR Company Inc. INSURER C 6411 Crystal Brook Dr INSURER D PERSONAL & ADV INJURY $1,000,000 Tampa, FL 33625 INSURER E INSURER F 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. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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. LTR TYPE OF INSURANCE ADDLSUBR NSR WVD POLICY NUMBER POLICY EFF (MM /DD /YYYY) POLICY EXP (MM /DD /YYYY) LIMITS A GENERAL LIABILITY Y 20083139 0912512015 091251201 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISESOERENT'E'D rence $ 300,000 CLAIMS -MADE Fx_] OCCUR MED EXP (Any one person) $10,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP /OP AGG $2,000,000 X POLICY PRO- JECT LOC $ A AUTOMOBILE LIABILITY 20083139 0912512015 091251201 CND Ee acccien SINGLE LIMIT $$1,000,000 BODILY INJURY (Per person) $ ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ X PROPERTY DAMAGE Per accident $ HIRED AUTOS X NON -OWNED AUTOS UMBRELLA LAB EACH OCCURRENCE $ HOCCUR AGGREGATE $ EXCESS LAB CLAIMS -MADE DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N] N/A Y 20043491 0912512015 091251201 X WT&SY LMITS EORH E.L. EACH ACCIDENT $100,000 E.L. DISEASE - EA EMPLOYEE $100,000 (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Waiver of subrogation applies in favor of certificate holder as respects to General Liability and Workers Compensation only if required by written contract, and subject to the terms, conditions and limits as specified in the policy. (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ENGINEERING DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. ATTN: CATHY TEFFT, ROOM 220 100 S. MYRTLE AVE. AUTHORIZED REPRESENTATIVE CLEARWATER, FL 33756 © 1988 -2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD #S275457/M270668 TERMA DESCRIPTIONS (Continued from Page 1) NOTICE Bouchard Insurance is required to comply with the licensing agreement we hold with ACORD. ACORD, in conjunction with the Department of Insurance, creates and enforces the rules and regulations pertaining to proper use of the Certificate of Liability Insurance form. We are required to mark a Y next to the line of business in which the Additional Insured or Waiver of Subrogation coverage applies. According to ACORD, the Description of Operations section must be limited to describing information necessary to identify the operations, locations and vehicles for which the certificate was issued. Please note the Description of Operations section of the Certificate cannot be used to add additional information except as just described. Marking a Y next to the line of business adequately documents coverage. Equally important, it satisfies the rules and regulations governing the proper use of the Certificate of Liability Insurance form. Certificate is a reflection of the current coverages provided for the insured. Limits and coverages are afforded to the certificate holder only if required by written contract. RE: GROSZ CONSTRUCTION COMPANY, INC. AND TIM GROSZ LICENSE #CGC- 1513014 SAGITTA 25.3 (2010/05) 2 of 2 #S275457/M270668