2015 STORMWATER PIPE LINING PROJECT - 15-0023-EN - CERTIFICATE OF LIABILITY INSURANCEAC"REO CERTIFICATE OF LIABILITY INSURANCE 10/12/2015
THIS CERTIFICATE IS ISSUED AS A FATTER 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 LIC 1t0G62759 1- 4.15 -486 -7000 CONTACT
NAME:
Aon Risk Insurance services West, Inc. PNON.� ... .. ........ — ...... FAX
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUER 'TO THE INSURED NAMED ABOVE FOR 'THE, PO ICr PEW FF
INDICATED. NOTWITHSTANDING ANY REQUIREME'N'T, 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.
_ . .. .... — -- .........
'WN3R. ........ ADDL 9`0113A 1rt ......... ....
POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE INSR WVQ1 POLICY NUMBER MMWDDr Y'YY MMiDO YYYY
A
GENERAL LIABILITY X
X
GL2074978689
10 /01/15 10/01/181 EACH OCCURRENCE 0'2,000,000
...
X COMMERCIAL GENERAL LIABILITY
f?AM1ARGETSJ RM"i°L°. "i. .I ._
PREMISES { p pCr� nce]. ..... 2 q q.. qqq .
j CLAIMS -MADE I OCCUR
MED EXP (Any one por,dnl $ NIL — ...
X. Contractual Liability
PERSONALBADVINJURY 2 qqq qqq
X
XCU'Hazards
GENERAL AGGREGATE $10,000,000
.. ..........._.._ ........ ........
....
GEN "t.. AGGREGATE L IMIT APPLIES" Pt'�R-
PRODUCTS - COMPJOP AGO 5 2 0 0 0 000
POLICY ` X PRG- ' LOC
JECI
j m
A
AUTOMOBILELIAB�LTY
X X BUA2074978692 10/g1/15
1q/g1/18' CCM13tNEDSINGLE LIMIT
X ANY AUTO
BODILY INJURY (Per person)
, -._ .......r �._.,.._ ......� ..,.._ _ .............. _....
......,m.
ALL OWNED SCHEDULED
BODILY INJURY (Per arriddntj
AUTOS AUTOS
NCfCN- GNfNED
PRC7PW illy DAMAGE
X HIRED AUTOS 1C AU "I "OS
(EVr Fp.�enL .. -._
X Contractua
3
UMBRELLA LIAR OCCUR
—ON
EACH (OCCURRENCE ,
_ .
4DED
EXCESS LIAR G LAWS -MADE
AGGREG ATE
R.ETE.NTI S
A
WORKERS COMPENSATION
X WC274978644 (AOS) 10/01./1 10/01/18
X TCIRb LIh71TS.1...
A
AND EMPLOYE'R'S'" LIABILITY YIN
ANY PRGPRIETORIPARTNERIEXECUTIVE7
WC27497863p (CA) 10/01/1. 10/01/18
-- ..._..
EL EACH ACCIDENT , s 2 000,'000
DFFICORIMEMBER EXCLUDE D7N
M
(Mandatory
P A
E.L. DISEASE .. - -- ....
EMPLOYEE 2 qqq , 0 0 q
dechm under
if yes, dwascal
N
i
EASE POLICY LIGhd IT 000,000
O
DESCRIPTION F OFF.RA11ONS belraw
_... _ �. . �.....__ _. . ....._......
I
E L DIS....
- �2
DESCRIPTION OF OPERATIONS) LOCATIONS! VEHICLES (Attach ACCORD 101, Additional Remarks Schedule, WT more space is required)
Job No.: 2015 5torrnwa+ter Pipelining Project
Contract No. 1.5 -0023 -817
Certificate bolder is named as an Additional Insured per the attached endorsements.
CIL PER ISO FORDS CGO001 10/01; AL PER ISO FORM CA0001 03/10
RTIFICATE HOLDER
City of Clearwater
Engineering Department
Construction Office Specialist
P.O. Box 4748
Clearwater,, FL 33758 -4748
ACORD 25 (2010!0 a)
lisa.kcc
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
USA (Ian 91iJ4 ,7wutcurce SeYwraa went, 3"r-
C71988 -2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACCORD
G-140331-D
(Ed. 01/13)
L A
Policy# GL2074978689
Insurance Company: Valley Forge Insurance Co.
Effective: 10-1-15
It is understood and agreed that this endorsement amends the COMMERCIAL GENERAL LIABILITY COVERAGE
PART as follows;
Aarne of Additional Insured Persons • OrEanizations
I
(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 11 - 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.
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" caused in whole or in part by:
a. Your acts or omissions, or the acts or omissions of those acting on your behalf, in the performance of
your ongoing operations specified in the ''written contract"; or
b. "Your work" that is specified in the "written contract" but only for "bodily injury" or "property damage"
included 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.
2. If the "written contract" specifically requires you to provide additional insurance coverage via the 10101
edition of CG2010 (aka CG 20 10 10 01), or via the 10/01 edition of CG2037 (aka CG 20 37 10 01), or via
the 11/85 edition of CG2010 (aka CG 20 10 11 85), then in paragraph 13.1. above, the words "Caused in
whole or in part by' are replaced by the words 'arising out of
3, We will not provide the additional insured any broader coverage or any higher limit of insurance than
a. The maximum permitted by law;
b. That required by the "written contract";
c. That described in B.1. above; or
d. That afforded to you under this policy,
G-140331-D (Ed. 011/13)
Page 1 of 3
Copyright, CNA All Rights Reserved.
whichever is less,
G-140331-D
(Ed. 01113)
4. Notwithstanding anything to the contrary in Condition 4. Other Insurance (Section IV), this insurance is
excess of 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,
5. The insurance provided to the additional insured does not apply to "bodily injury," "property damage,'' or
"personal and advertising injury" arising out of:
a. 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
b. 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 13.4. 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 -14 3331 -D (Ed. 01113)
Page 2 of 3
Copyright, CNA All Rights Reserved.
A
G-.140331-D
(Ed. 01/13
Waiver of Transfer of Rights of Recovery Against Others to U's
Under SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, The Transfer Of Rights Of Recovery
Against Others To Us Condition is amended by the addition of the following:
We waive any right of recovery we may have against any person or organization because of payments we make for
injury or damage arising out of:
1. Your ongoing operations; or
2. "Your work" included in the "products completed operations hazard.''
However, this waiver applies only when you have agreed in writing to waive such rights of recovery in a contract or
agreement, and 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.
In the event of cancellation or material change that reduces or restricts the insurance afforded by this Coverage Part
(other than the reduction of aggregate limits through payment of claims), we agree to mail prior written notice of
cancellation or material change to:
SCHEDULE
1. Name: Any person or organization you are required by written contract or agreement to mail prior written notice
of cancellation or material change.
2. Address: Per Certificates of Insurance on file with the broker.
3. Number of days advance notice:
For non-payment of premium, the greater of:
• the number of days required by state statute or
• the number of days required by written contract
For any other reason, the lesser of:
• 60 days, or
a the number of days required in a written contract
Material used with permission of ISO Properties, Inc
G-000:00-A Page 3 of 3
(Ed. )
'11OLICY NUMBER: GL2074978689 C0011EIRCIAL GEAE,*I--.L LIABILITT
_nsurance Company: Valley Forge Insurance Co.
=ffective: N i 03 06 O 9
TYIS EIJD02SE
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Any construction project as required by a written contract or agreement that was executed prior to the date of
loss.
I Information required to complete this Schedule, if not shown above, will be shown in the Declarations. I
A For all sums which the insured becomes legally
obligated to pay as damages caused by
"occurrences'' under Section I — Coverage A, and
for all medical expenses caused by accidents
under Section I — Coverage C, which can be
attributed only to ongoing operations at a single
designated construction project shown in the
Schedule above:
1. A separate Designated Construction Project
General Aggregate Limit applies to each
designated construction project, and that limit
is equal to the amount of the General
Aggregate Limit shown in the Declarations.
2. The Designated Construction Project General
Aggregate Limit is the most we will pay for the
sum of all damages under Coverage A,
except damages because of "bodily injury" or
"property damage" included in the "products-
completed operations hazard," and for
medical expenses under Coverage C
regardless of the number of:
a. Insureds;
b. Claims made or "suits" brought; or
c. Persons or organizations making claims or
bringing ''suits."
3. Any payments made under Coverage A for
damages or under Coverage C for medical
expenses shall reduce the Designated
Construction Project General Aggregate Limit
for that designated construction project. Such
payments shall not reduce the General
Aggregate Limit shown in the Declarations
nor shall they reduce any other Designated
Construction Project General Aggregate Limit
for any other designated construction project
shown in the Schedule above.
4. The limits shown in the Declarations for Each
Occurrence, Damage To Premises Rented To
You and Medical Expense continue to apply,
However, instead of being subject to the
General Aggregate Limit shown in the
Declarations, such limits well be subject to the
applicable Designated Construction Project
General Aggregate Limit.
CG 25 03 05 09 Copyright, Insurance Services Office, Inc., 2008 Page 1 of 2
B. For all sums which the insured becomes legally C.
obligated to pay as damages caused by
" "occurrences'" under Section I — Coverage A, and
for all medical expenses caused by accidents
under Section I — Coverage C, which cannot be
attributed only to ongoing operations at a single
designated construction project shown in the
Schedule above:
1. Any payments made under Coverage A for
damages or under Coverage C for medical D.
expenses shall reduce the amount available
under the General Aggregate Limit or the
Products-completed Operations Aggregate
Limit, whichever is applicable; and
2. Such payments shall not reduce any
Designated Construction Project General
Aggregate Limit.
When coverage for liability arising out of the
"products - completed operations hazard" is
provided, any payments for damages because of
"bodily injury" or "property damage" included in
the ''products- completed' operations hazard'' will
reduce the Products- completed Operations
Aggregate Limit, and not reduce the General
Aggregate Limit nor the Designated Construction
Project General Aggregate Limit,
If the applicable designated construction project
has been abandoned, delayed, or abandoned
and then restarted, or if the aUthorized
contracting parties deviate from plans, blueprints,
designs, specifications or timetables, the project
will still be deemed to be the same construction
project.
E. The provisions of Section III — Urnits Of
Insurance not otherwise modified by this
endorsement shall continue to apply as
stipulated.
Page 2 of 2 Copyright, Insurance Services Office, Inc., 2008 CG 25 03 05 09
It is understood and agreed that this, endorsement amends the BUSINESS AUTO COVERAGE FORM as follows:
[-_160#3011111
Name of Additional Insured Persons Or Organizations
Any person or organization whom the named insured is required by written contract to add as an additional insured
on this pollcy.
1. In conformance with paragraph A.l.c. of Who Is An Insured of Section 11 — LIABILITY COVERAGE, the person
or organization scheduled above is an insured under this policy.
2. The insurance afforded to the additional insured under this policy will apply on a primary and non-contributory
basis if you have committed it to be so in a written contract or written agreement executed prior to the date of
the "accident" for which the additional insured seeks coverage under this policy.
Notice of Cancellation or Material Change- Designated Person or Organization
In the event of cancellation or material change that reduces or restricts the insurance afforded by this Coverage
Part, we agree to mail prior written notice of cancellation or material change to:
1. Name: Any person or organization you are required by written contract or agreement to mail prior written
notice of cancellation or material change.
2. Address: Per Certificates of Insurance on file with the broker.
3. Number of days advance notice:
For non-payment of premium, the greater of:
• the number of days required by state statute or
• the number of days required by written contract
For any other reason, the lesser of:
0 60 days or
0 the number of days required in a written contract
The Transfer Of Rights Of Recovery Against Others To Us Condition does not apply to the person(s) or
organization(s) shown in the Schedule, but only to the extent that subrogation is waived prior to the "accident'' or the
"loss" under a contract with that person or organization.
Schedule
Any person or organization for whom or which the named insured is required by written contract or agreement to
obtain this waiver from us.
All other terms and conditions of the Policy remain unchanged.
CNA71527XX (10/12) modified Policy No: BUA 2074978692
Effective Date: 16 -1 -16 Valley Forge Insurance Company
Copyright C NA All Rights Reserved,
A
G-20472-A
(Ed. 10/93)
WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY INSURANCE POLICY
m1wil k9 I 0�
In the event of cancellation or other material change of the policy, we will mail advance notice to the person or
organization named in the Schedule. The number of days advance notice is shown in the Schedule.
This endorsement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
1. Number of days advance notice:
For non-payment of premium, the greater of:
• the number of days required by state statute or
• the number of days required by written contract
For any other reason, the lesser of:
* 60 days or
* the number of days required in a written contract
Any person or organization you are required by written contract or agreement to mail prior written notice of
cancellation: or material change.
Address: Per Certificates of Insurance on file with the broker
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information below is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 10-1-15 Policy No.WC274978630 Valley Forge Insurance Company
VVC274978644 Valley Forge Insurance Company
WC274978658 Transportation Insurance Company
VVC274978661 Transportation Insurance Company
G-20472-A Page 1 of I
(Ed, 1 0/93)
Em".:k.
WORKERS'COMPENSATION AND EMPLOYERS'LIABILITY INSURANCE POLICY
This endorsement changes the policy to which bisattached.
B-1018Q-B
Uim agreed that Part One — Workers' Compensation Insurance G. Recovery From Others and Part Two — Employers' Liability
Insurance H. Recovery From Others; are amended by adding the following:
VVe will not enforce our right bo recover against persons ur organizations. (This agreement applies only ho the extent that you perform
work under a written contract that requires you to obtain this agreement from us.)
PREMIUM CHARGE —nia
The charge will bean amount tu which you and weagree that ba percentage of the total standard premium for California exposure.
The amount | .
This endorsement mppUma only to the insurance provided by the policy because Utah is shown in Item 3.A. of the Information
Page.
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not mnhznoa our MQht
against the person or organization named in the Schedule. (This agreement applies only to the extent that you perform work
under e written contract that requires you tm obtain this agreement from ue.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule, Our waiver of righits does not
release your employees' rights against third parties and does not release our authority as trustee of claims against third
parties, Schedule . Any person or organization for whom the named insured has agreed by written contract to furnish
this waiver,
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
All Other States where allowed (except CA, TX, UT)
VVe 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 mmnned in the Schedule. (Fh|m agreement applies only to the extent that you pedbnn *mnk under o 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
Any person or organization for whom the named insured has agreed by written contract to furnish this waiver
WCD00313(Ed 4-84l
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
(The information bellow is required only when this endorsement is issued subsequent to preparation of the policy.)
Endorsement Effective 10-1-15
Policy No. VVC27497883O
VVC274878644
VVC274978658
VYC274978681
Valley Forge Insurance Company
Valley Forge Insurance Company
Transportation Insurance Company
Transportation Insurance Company
E-19160-B Page of