GREENLEA-OTTEN NEIGHBORHOOD TRAFFIC CALMING & OTTEN ST ROADWAY & STORMWATER IMPROVEMENT PROJECT - 10-0003-EN - CERTIFICATE OF LIABILITY INSURANCEDAVINEL -01 JFAVA
T
.4C"MEY
44� CERTIFICATE OF LIABILITY INSURANCE
DATE (MNMDDNYYY)
4/25/2016
THIS CERTIFICATE €S 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(les) 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
ASSOCIATES AGENCY, INC.
11470 N 53rd St
Temple Terrace, FL 33617
CONTACT
NAME:
PH- N {813) 988 -1234 JAIL No l: (813) 988 -0989
ADDRESS. Carts a$SOClatesinS.COm
INSURER(S) AFFORDING COVERAGE
NAIC 0
INSURER A: National Trust Ins. Co.
20141
INSURED
INsuRER a: FOCI INSURANCE CO.
10178
INSURER C : Certain Underwriters at Lloyds
David Nelson Construction Co.
INSURER D,
3483 Alternate 19
INSURER E:
0510112017
Palm Harbor, FL 34683
INSURER F
MED EXP (Any one n
$ 5,00
e,emirOerFe r'_FRTIFtr_ATF NIIMPFR- 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
LTii
TYPE OF INSURANCE
POLICY NUMBER
WN EFF
MM! E1tP
LIMITS
A
X
COMMERCIAL GENERAL lUABILrrY
EACH OCCURRENCE.
$ 1,000,00
CLAIMS MAI]E OCCUR
GL 0010298-07
0516112076
0510112017
PREMISESTO Ea occurrence
$ 100,00
MED EXP (Any one n
$ 5,00
X
Contractual Liab.
PERSONAL & ADV INJURY
$ 1,000,00
GEN'LAGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$ 2,000,00
PRODUCTS - COMPIOP AGG
$ 2,000,00
POLICY [K JPERa LOC
EMPLOYEE BENEFI
$ 1,000,00
OTHER:
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
Ea aCCidBM
$ 1 ,000,00
BODILY INJURY (Pal person)
S
A
x ANY AUTO
A 0015954 -07
0510112016
OW0112017
BODILY INJURY (Par accident)
$
ALL OWNED SCHEDULED
AUTOS AUTOS
NON -OWNED
X HIRED AUTOS X AUTOS
PROPERTY DAMAGE
accident)
$
Pip
$ 10,00
X
UMBRELLA LIAR
X OCCUR
EACH OCCURRENCE
$ 10,000,000
AGGREGATE
$ 10,000,00
A
ExMS LIAR
CLAIMS -MADE
UMBOOID683 -07
06101/2016
06101/2017
Tt)EO X I RETENTION $ 101000
$
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTNERIEKECUTIVE Y❑
001 WC1sA -65778
01/01/2016
01/0112017
x STATUTE ER
E_L_ EACH ACCIDENT
E 600,00
OISEASE- EA EMPLOYEE
E 300,00
(Mandatory In NH) EXCLUDED? F-1
NIA
E.L DISEASE - POLICY LIMIT
S 300,00
H yea describe under
DESCRIPTION OF OPERATIONS betoW
I
C
Pollution/Profession
16 -212
05/0112016
05/01/2017
OCC $2,000,000 Agg 2,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (ACORD 101, Addlional Remarks Schedule, nwy be attached it more spaea is required]
Project: G ream lea-Often NoIghborhood Traff€c Calming, Roadway & Stonnwater Improvements Project No 10-0003 -EN
City of Clearwater Engineering Department is an additional Insured with regard to the general liability where required by written contract A waiver of
subrogation applies In favor of the additional insured with regard to the general liability and workers compensation where requ €red by written contract. The
General liability is primary and non contributory. A 30 day notice of cancellation applies with 10 days for non payment in regard to the general I lab] IIty , auto
liability, and workers compensation.
reoTlGlre7l1= wnl nFR r-ANr.FI T ATICIN
C) 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
C€ of Clearwater En ineerin De rtment
City g g
100 S. Myrtle Ave
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater, FL 33756
AUTHORIZED REPRESENTATIVE
6
C) 1988 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014101) The ACORD name and logo are registered marks of ACORD