CERTIFICATE OF LIABILITY INSURANCE (673)ACORtir CERTIFICATE OF LIABILITY INSURANCE
DATE(MM /DD/YYYY)
12/4/2015
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 endorsements).
PRODUCER
McGowan Insurance Group, Inc.
355 Indiana Avenue
NAME: CONTACT Daniel Gable
PHONE t (317) 464 -5000 a (317)464 -5001
E -MAIL danielg@mcgowaninc.com
ADDRESS: gQmC g OwaninC. COm
Suite 200
Indianapolis IN 46204
INSURERS AFFORDING COVERAGE
NAIC #
INSURERA:Colony Insurance Company
36927
INSURED
R2J Chemical Services, Inc.
12345 62nd St. North
Unit #D
Largo FL 33773
INSURER B :FCCI Insurance Group
10178
INSURERC:FEDERAL INSURANCE COMPANY
20281
INSURER D:
INSURER E:
$ 1, 000, 000
INSURER F:
CLAIMS -MADE � OCCUR
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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
UBR
POLICY NUMBER
POLICY EFF
POLICY EXP
LIMITS
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE
$ 1, 000, 000
A
CLAIMS -MADE � OCCUR
DAMAGE TO RENTED
PREMISES Ea occurrence
$ 100,000
X
MED EXP (Any one person)
$ 10,000
Contractors Pollution
EPK304197
12/2/2015
12/2/2016
X
Errors & Omissions
PERSONAL & ADV INJURY
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,000
POLICY � IOC
JECOT-
PRODUCTS- COMP /OPAGG
$ 2,000,000
X OTHER:Contractual Liabilit
$
AUTOMOBILE
LIABILITY
O a INEDtSINGLE LIMIT
(Ea
$ 1,000,000
BODILY INJURY (Per person)
$
B
ANY AUTO
ALL OWNED SCHEDULED
AUTOS AUTOS
CA 0031380
12/2/2015
12/2/2016
X
BODILY INJURY Per accident
( )
$
HIRED AUTOS X NON -OWNED
AUTOS
X
PROPERTY DAMAGE
Per accident)
$
$
UMBRELLA LIAB
X
OCCUR
EACH OCCURRENCE
$ 5,000,000
X
AGGREGATE
$
C
EXCESS LIAB
CLAIMS -MADE
010 -WC16A -74339
DE D RETENTION$
$
12/2/2015
12/2/2016
WORKERS COMPENSATION
_
Y
AND EMPLOYERS' LIABILITY Y / N
STATUTE ERH
E.L. EACH ACCIDENT
$ 1,000,000
ANY PROPRIETOR /PARTNER /EXECUTIVE
OFFICER/MEMBER EXCLUDED?
NIA
B
(Mandatory In NH)
If yes, describe under
WC01301170
1/1/2016
1/1/2017
E.L. DISEASE - EA EMPLOYE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
The following applies when required by written agreement: General Liability Primary and Non - Contributory
Additional Insured per form EV200 -1012; General Liability waiver of Subrogation per form EV152 -0609; Auto
Liability Additional Insured Primary /Non Contributory per form CAU 042 (12 08); Auto Liability Waiver of
Subrogation per form CAU 014 (04/04). Excess Liability follows form of the above captioned General
Liability, Auto, and Work Comp policies. Workers compensation blanket waiver of subrogation. This
Certificate is subject to the terms and conditions of the scheduled policies.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
CITY OF CLEARWATER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
100 S. MYRTLE AVENUE ✓�G<" ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater, FL 33756 Fr)�
AUTHORIZED REPRESENTATIVE
Michael Highum /DANIEL
V i ass -ZU14 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
I NS025 (201401)