CERTIFICATE OF LIABILITY INSURANCE (692)ACOREI CERTIFICATE OF LIABILITY INSURANCE
‘m.../
DATE(MM /DD/YYYY)
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
Jack Rice Insurance
13080 S Belcher Rd
Largo FL 33773
CONTACT Commercial Lines Division
NAME:
(A/C. (727) 530 -0684 (A/C. No). (727) 532 -9602
E-MAIL
ADDRESS:
INSURERS) AFFORDING COVERAGE
NAIC I
INSURER A:Southern- Owners Ins. Co.
10190
INSURED
Scotto Plumbing Service Inc.
PO Box 1632
Clearwater FL 33757 -1632
INSURER B Auto- Owners Ins. Co.
18988
INSURERC:
7 18/2017
,� -s
INSURER D :
$ 1,000,000
INSURER E :
INAuRERF:
X
COVERAGES
CERTIFICATE NUMBER:CL1621744412
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
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POUCY EFF
(MM /DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
20479726 f
2Y9��•.�.._
qi?
s {' ::
2� / 1,Dir
:; ((
7 18/2017
,� -s
EACH OCCURRENCE
$ 1,000,000
CLAIMS MADE
X
OCCUR
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$ 50 , 000
X
X
PD- Deductible S10,000
MED EXP (Any one person)
$ 5,000
Per Occurrence
PERSONAL BADVINJURY
$ 1,000,000
GEN'L
X
AGGREGATE
POLICY
OTHER:
X
LIMIT APPLIES
JECOT-
PER:
LOC
GENERAL AGGREGATE
$ 1,000,000
PRODUCTS - COMP/OP AGG
$ 1,000,000
Voluntary Property Damage
$ 5,000
B
AUTOMOBILE
X
X
UABIUTY
ANY AUTO
ALLOWNED
AUTOS
HIRED AUTOS
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS
OM /
�^
� 4 sir ✓ i 7
4347972600
a C c .yiM
{{
, ''g � + 1 :....r
2/18/2016
a ,.!
,„,;;....i" i
2/18/2017
COMBINED tSINGLE LIMIT
$ 1,000,000
BODILY INJURY Per n
(Per )
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
A
X
UMBRELLA UAB
EXCESS UAB
X
OCCUR
CLAIMS -MADE
Underlying: Auto /GL
4753990301
2/18/2016
2/18/2017
EACH OCCURRENCE
$ 2,000,000
AGGREGATE
$ 2,000,000
DED
RETENTON$
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER /EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / H
NIA
1 PER
L STATUTE
I OTH-
ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
A
RENTED /LEASED EQUIPMENT
20479726
2/18/2016
2/18/2017
LIMIT: 22,000
DEDUCTIBLE: 500
DESCRIPTION OF OPERATIONS I LOCATIONS / TelrieZEMBEI01, Additional Remarks Schedule, may be attached if more space is required)
FEB 2 2 2016
GAS ADMIN
CERTIFICATE HOLDER
CANCELLATION
( ) -
City of Clearwater
400 N. Myrtle Ave
Clearwater, FL 33755
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
Cynthia Webster /LPW /•711.
V 1983 -2014 ACORD CORPORATION. All rights reserved.
ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD
INS025 (7014n11
COMMENTS /REMARKS
GENERAL LIABILITY:
Automatic Additional Insureds when required by Written Contract with Products /Completed
Operations per form 55373 01/07.
Scheduled Additional Insureds for Lessors (equipment) operations only per form 55183
12/04.
Primary & Non - Contributory Coverage for Additional Insureds on an Automatic Basis when
required by Written Contract per form 55373 01/07.
Waiver of Subrogation for Additional Insureds on a Scheduled Basis per form CG2404 10/93.
AUTOMOBILE LIABILITY:
Automatic Additional Insureds when required by Written Contract for Contractors per form
89304 07/10.
Scheduled Loss Payees per Policy.
Hired Auto Physical Damage Included with $50,000 Limit
Comp /Coll Deductibles: $100/$250
INLAND MARINE:
Scheduled Loss Payees per Policy.
OFREMARK COPYRIGHT 2000, ANS SERVICES INC.