CERTIFICATE OF LIABILITY INSURANCE (662)CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYI�
09/23/20t5
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
MARSH USA, INC. NAME:
445 SOUTH STREET PHONE Fax
MORRISTOWN, NJ 07960-6454 E-MAIL A/C No :
100129-fr78A-SBT1-15/16
INSURED
SIEMENS INDUSTRY, INC.
BUILDING TECHNOLOGIES
1000 DEERFIELD PARKWAY
BUFFALO GROVE, IL 60089
240 LEMBO
iNSUReR n: HDI-Gerling America Insurance Company
iNSUReR e: The Travelers Indemnity Company
iNSURER c: Travelers Properry Casualty Co. of America
INSURER E :
343
COVERAGES CERTIFICATE NUMBER: NYC-007205905-28 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 ADDL SUBR
LTR TYPE OF INSURANCE POLICY NUMBER MM DDMIYY MM/DDlYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY GLD1110107 10/01/2015 10/O112016 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE a OCCUR PREM SES Ea occTu D nce $ 1,000,000
MED EXP (Any one person) $ ��,��
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 10,000,000
X POLICY ❑ PRO- ❑
JECT LOC PRODUCTS-COMP/OPAGG $ INCL
OTHER: $
C AUTOMOBILE LIABILITY TC2JCAP7440L34A15 10/01/2015 10/01/2016 COMBINED S�NGLF LIMIT g 2,0OO,OGO
Ea accident
X ANY AUTO BODILY INJURY (Per person) $ NIA
X ALLOWNED SCHEDULED
AUTOS AUTOS BODILY INJURY (Per accident) S NIA
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE
AUTOS Per accident $ N/A
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE
AGGREGATE $
DED RETENTION $ $
C WORKERSCOMPENSATION TC2JUB7440L27115(AOS) 'IO/Ol/2Oi5 'IO/O1I2O1B X PER OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
B ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N TRKU67440L28315 (AZ, MA, OR S WI� 'IOIOIIZO'I5 'IOIO1/2O1G E.L. EACH ACCIDENT $ 'I,OOO,OOO
C OFFICER/MEMBER EXCLUDED? � N� A
(Mandatory in NH) TWXJU67440L33815 (OH & WA) 1�/0�/2015 ��/�1�2�16 E.L. DISEASE - EA EMPLOYEE $ 1,0��,000
If yes, describe under ""'$500K LIMIT /$SOOK SIR""'
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Atlditional Remarks Schedule, may be attached if more space Is required)
RE: CONTRACTOR LICENSE REGISTRATION FOR THE BRANCH
JEREMY LEMBO LICENSE 19212100012010, EF20001115 ARE INCLUDED AS ADDITIONAI INSURED UNDER THE REFERENCED GENERAL LIABILITY AND AUTOMOBILE LIA�ILI7X1N5URANCE
POLICIES, BUT ONLY WITH RESPECT TO ALL WORK PERFORMED BY AND ON BEHALF OF THE NAMED INSURED, SIEMENS INDUSTRY, INC. FOR CERTIF�CATE H�tDE'i2'UNbER CONTWIC7:
COVERS ALL EMPLOYEES IN THE STATE Of FLORIDA.
^ �� . ,
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CERTIFICATE HOLDER _ CANCELLATION
THE CITY OF CLEARWATER
ATTN: CONTR,4CTOR LICENSING
100 SOUTH MYRTLE ROAD
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
of Marsh USA Inc.
IManashi Mukherjee ,,,'�,�A,,,a,�ti,,:. �„�,,�
�O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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