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CR 193 - GROVE CIRCLE AND BELCHER AREA SANITARY SEWER SYSTEMS - 13-0049-UT - CERTIFICATE OF LIABILITY INSURANCE - 13-0049-UTDALL1CO -01 LALLEN ' 10. R CERTIFICATE OF LIABILITY INSURANCE �� DATE 0/1 /2D/YYYY) 10/1 /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 NAME: Linda Allen Florida Insurance Center, Inc. 414 N Alexander St Plant City, FL 33563 PHONE FAx A/c No Ext : ( 813 ) 754 -3561 (A/C, No): ( 813 ) 754 -3450 ADDRES& INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Westfield Insurance Company 24112 INSURED INSURER B: FCCI Insurance Co 10178 Dallas 1 Corporation dba Dallas 1 Construction & INSURERC: Development dba Tampa 1 10328 E. Main Street INSURER D 10/01/2016 INSURER E : DAMAGE TO RENTED PREMISES Ea occurrence Thonotosassa, FL 33592 INSURER F: MED EXP (Any one person) $ 5,000 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 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 /DD /YYYY POLICY EXP MM /DD /YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XII OCCUR X CMM3987019 10/01/2015 10/01/2016 DAMAGE TO RENTED PREMISES Ea occurrence 5OO OOO $ , MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT [::] LOC PRODUCTS - COMP /OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ 1000000 , , X BODILY INJURY (Per person) $ A ANY AUTO CMM3987019 10/01/2015 10/01/2016 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ A EXCESS LAB CLAIMS -MADE CMM3987019 10/01/2015 10/01/2016 DED X RETENTION $ 0 $ 10,000,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE Y OFFICER /MEMBER EXCLUDED? (Mandatory in NH) N /A 63241 01/01/2015 01/01/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 • Leased /Rented Equip CMM3987019 10/01/2015 10/01/2016 Max Limit 500,000 • Installation Fltr CMM3987019 10/01/2015 10/01/2016 Any Location 1,100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Clearwater is named as additional insured with regards to general liability as required by written contract. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) © 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater Development &Neighborhood Services Deparrtment THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 100 S. Myrtle Ave Ste 210 AUTHORIZED REPRESENTATIVE Clearwater, FL 33756 ACORD 25 (2014/01) © 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD DALL1CO -01 LALLEN ' 10. R CERTIFICATE OF LIABILITY INSURANCE �� DATE 0/1 /2D/YYYY) 10/1 /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 NAME: Linda Allen Florida Insurance Center, Inc. 414 N Alexander St Plant City, FL 33563 PHONE FAx A/c No Ext : ( 813 ) 754 -3561 (A/C, No): ( 813 ) 754 -3450 ADDRES& INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Westfield Insurance Company 24112 INSURED INSURER B: FCCI Insurance Co 10178 Dallas 1 Corporation dba Dallas 1 Construction & X X Development INSURER C : 10/01/2016 INSURER D: DAMAGE TO RENTED PREMISES Ea occurrence dba Tampa 1 Technology Solutions 10328 E. Main Street Thonotosassa, FL 33592 INSURER E: $ 5,000 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 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 /DD /YYYY POLICY EXP MM /DD /YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE 1XII OCCUR X X CMM3987019 10/01/2015 10/01/2016 DAMAGE TO RENTED PREMISES Ea occurrence 500 000 $ , MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY PRO- JECT [::] LOC PRODUCTS - COMP /OPAGG $ 2,000,000 $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident) $ 1000000 , , X BODILY INJURY (Per person) $ A ANY AUTO X X CMM3987019 10/01/2015 10/01/2016 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,000 AGGREGATE $ A EXCESS LAB CLAIMS -MADE X X CMM3987019 10/01/2015 10/01/2016 DED X RETENTION $ 0 $ 10,000,000 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE Y OFFICER /MEMBER EXCLUDED? (Mandatory in NH) N /A X 63241 01/01/2015 01/01/2016 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 • Leased /Rented Equip CMM3987019 10/01/2015 10/01/2016 Max Limit 500,000 • Installation Fltr CMM3987019 10/01/2015 10/01/2016 Any Location 1,100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Project: C.R. 193, Grove Circle and Belcher Area Sanitary Sewer Systems (13- 0049 -UT) City of Clearwater is named as additional insured with regards to general liability as required by written contract. All Policies are primary and non contributory. Waiver of subrogation applies. CERTIFICATE HOLDER CANCELLATION ACORD 25 (2014/01) © 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater Engineering Department Attn: Construction Office Specialist THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. P O Box 4748 AUTHORIZED REPRESENTATIVE 33758 -4748 ACORD 25 (2014/01) © 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Dallas 1 Corporation POLICY NUMBER: CMM 3987019 INTERLINE THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. EARLIER NOTICE OF CANCELLATION PROVIDED BY US This endorsement modifies insurance provided under the following: COMMERCIAL AUTO COVERAGE PART CRIME AND FIDELITY COVERAGE PART EQUIPMENT BREAKDOWN COVERAGE PART FARM COVERAGE PART COMMERCIAL PROPERTY COVERAGE PART COMMERCIAL INLAND MARINE COVERAGE PART COMMERCIAL LIABILITY UMBRELLA COVERAGE PART OWNERS AND CONTRACTORS PROTECTIVE LIABILITY COVERAGE PART COMMERCIAL GENERAL LIABILITY COVERAGE PART LIQUOR LIABILITY COVERAGE PART PROFESSIONAL LIABILITY COVERAGE SCHEDULE Number of Days' Notice 3 0 --------- - - - - -- Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations City of Clearwater Engineering Dept Attn: Construction Office Project: C.R. 193, Grove Circle and P O Box 4748 Belcher Area Sanitary Sewer Systems Clearwater, FL 13- 0049 -UT (if no entry appears above, information required to complete this Schedule will be shown in the Declarations as applicable to this endorsement.) For any statutorily permitted reason other than nonpayment of premium, the number of days required for notice of cancellation, as provided in paragraph 2. of either the CANCELLATION Common Policy Condi- tion or as amended by an applicable state cancellation endorsement, is increased to the number of days shown in the Schedule above. Copyright, Insurance Services Office, Inc., 1992 IL 70 35 09 12 Dallas 1 Corporation POLICY NUMBER: CMM 3987019 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) Of Covered Operations City of Clearwater Engineering Department P o Box 4748 Project: C.R. 193, Grove Circle and Clearwater FL 33758 -4748 Belcher Area Sanitary Sewer Systems (13- 0049 -UT) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury ". "property damage" or "personal and adver- tising injury" caused, in whole or in part, by: 1. Your acts or omissions: or 2. The acts or omissions of those acting on your behalf: in the performance of your ongoing oper- ations for the additional insured(s) at the location(s) designated above. However: 1. The insurance afforded to such additional insured only applies to the extent per- mitted by law; and 2. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following addi- tional exclusions apply: This insurance does not apply to "bodily in- jury" or "property damage" occurring after: 1. All work, including materials, parts or equipment furnished in connection with such work. on the project (other than service, maintenance or repairs) to be performed by or on behalf of the addi- tional insured(s) at the location of the covered operations has been completed; or 2. That portion of "your work" out of which the injury or damage arises has been put to its intended use by any person or or- ganization other than another contractor or subcontractor engaged in performing operations for a principal as a part of the same project. C. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the ap- plicable Limits of Insurance shown in the Declarations. © Insurance Services office, Inc., 2012 CG 20 10 04 13 Dallas 1 Corporation POLICY NUMBER: CMM 3987019 COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Location(s) And Description Of Covered Operations City of Clearwater Engineering Department P O Box 4748 Project: C.R. 193, Grove Circle and Clearwater FL 33758 -4748 Belcher Area Sanitary Sewer Systems (13- 0049 -UT) Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury" or "property damage" caused, in whole or in part, by "your work" at the location desig- nated and described in the schedule of this endorsement performed for that additional insured and included in the "products - completed operations hazard ". However: 1. The insurance afforded to such additional insured only applies to the extent per- mitted by law; and 2. If coverage provided to the additional in- sured is required by a contract or agree- ment, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement. the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the ap- plicable Limits of Insurance shown in the Declarations. © Insurance services office, Inc., 2012 CG 20 37 04 13 CMM 3987019 Dallas 1 Corporation POLICY NUMBER: COMMERCIAL GENERAL LIABILITY THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS /COMPLETED OPERATIONS LIABILITY COVERAGE PART SCHEDULE Name Of Person Or Organization: Any person or organization for whom you are required in a written contract or agreement to include a waiver of transfer of rights of recovery against others to us, provided the "bodily injury" or "property damage" occurs subsequent to the execution of the written agreement. Information required to complete this Schedule, if not shown above, will be shown in the Declarations. The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section IV - Conditions: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or "your work" done under a contract with that person or organization and included in the "products - completed operations hazard ". This waiver applies only to the person or organization shown in the Schedule above. © Insurance services Office, Inc., 2008 CG 24 04A 05 09