STORMWATER OUTFALL PIPE CLEANING - 13-0045-EN - CERTIFICATE OF LIABILITY INSURANCE (3)ECEiVED
Date
Y '� 13
DATE (MM /DD )
ACOR" CERTIFICATE OF LIABILITY INSURANCE 05/04/201
THIS S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UP N THE ATE HOLDER. HIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVE-
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
MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC.
818 Town & Country Blvd, Suite 500
Houston, TX 77024 -4549
CONTACT
NAME:
PHONE 713- 877 -8975 FAX 713- 877 -8974
vc No Ext : A/c, No
E -MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
100 SOUTH MYRTLE AVENUE
INSURER A :Zurich American Insurance Company
16535
1,
INSURED
LAYNE INLINER, LLC
2531 JEWETT LANE
INSURER B :Lexington Insurance Company
19437
INSURER C :American Zurich Insurance Company
40142
INSURER D:
SANFORD, FL 32771
INSURER E :
INSURER F:
...,..cow. -cc CERTIFICATE NUMRER•7RPJ1 DK3 REVISION NUMBER:
CERTIFICATE
%1WV ___
.. ._ .. �...__...__-
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.
ADDL sUBR POLICY EFF POLICY EXP
rt 7F-
GEN'L RANCE INSD WVD POLICY NUMBER MM /DD/YYYY MM /DD /YYYY LIMITS
AL LIABILITY GILD 0194362 -00 05/01/2016 08/01/2017 EACH OCCURRENCE $ 1,250,000
A 1,000,000
OCCUR PREMISES Ea occurrence $
MED EXP (Any one person) $ 10,000
PERSONAL & ADV INJURY $ 2,000,000
APPLIES PER: GENERAL AGGREGATE $ 10,000,000
X POLICY ❑ ❑ LOC PRODUCTS - COMP /OP AGG $ 10,000,000
JECT
OTHER:
A AUTOMOBILE LIABILITY BAP 0194359 -00 05/01!2016 08(01/2017 COMBINED SINGLE LIMIT 5,000,000
Ea accident $
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS NON -OWNED PROPERTY DAMAGE $
Per accident
HIRED AUTOS AUTOS $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS -MADE AGGREGATE $
DED RETENTION $ $
C WORKERS COMPENSATION WC 0194360-00 AOS) 05/01/2016 05/01/2017 X PER OTH-
AND EMPLOYERS' LIABILITY WC 0194361 -00 (WI & MA) STATUTE ER
Y / N 5,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? N / A` 5,0001000
;Mandatory in NH) E.L. DISEASE - EA E.- APLOYEE $
If yes, des, ba under 5,000,000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
B Contractors Equipment 026159794 08/01/2015 08/01/2016 All Leased, Owned or
Rented Equipment $
Per Occurrence: $ 5,000,000
$
$
DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: Stormwater Outfall Pipe Cleaning ( #13- 0045 -EN), Various Locations in the City of Clearwater
Certificate holder is included as an Additional Insured on the General Liability and Automobile Liability policies as required by written contract and granted Waiver of
Subrogation on the General Liability, Automobile Liability and Workers Compensation policies (except Workers' Compensation for the State of MA) as required by written
contract subject to policy terms, conditions and exclusions. In the event of cancellation by the insurance company(ies) the General Liability and Automobile Liability policies
have been endorsed to provide (30) days Notice of Cancellation (except for non - payment) to the certificate holder shown below.
IFICATE HOLDER CANCELLATION
CERT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY OF CLEARWATER
AUTHORIZED REPRESENTATIVE /
100 SOUTH MYRTLE AVENUE
CLEARWATER, FL 33756
1,
IFICATE HOLDER CANCELLATION
CERT
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
CITY OF CLEARWATER
AUTHORIZED REPRESENTATIVE /
100 SOUTH MYRTLE AVENUE
CLEARWATER, FL 33756
1,
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