CERTIFICATE OF LIABILITY INSURANCE (398)DATE (MM/DD/YYYY)
��' � � CERTIFICATE OF LIABILITY INSURANCE
�,,,,.--� 05/19/2016
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 CONTACT
Automatic Data Processing Insurance Agency, Inc.
1 Adp Boulevard
Roseland, NJ 07068
INSURED
INGENIUM ENTERPRISES INC
4600 W CYPRESS ST STE 550
Tampa, FL 33607
COVERAGES
CERTIFICATE NUMBER: 494322
INSURER(S) AFFORDING COVERAGE
INSURER A: Travelers Casualty and Surety Company
INSURER B :
INSURER C :
INSURER D :
INSURER E :
INSURER F :
REVISION NUMBER:
NAIC #
19038
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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE � OCCUR DAMAGETORENTED
PREMISES Ea occurrence $
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY � PR� � LOC PRODUCTS - COMP/OP AGG $
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
ANY AUTO BODILY INJURY (Per person) $
ALLOWNED SCHEDULED BODILYINJURY(Peraccident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ N E.L. EACH ACCIDENT $ ��OOO�OOO
A OFFICER/MEMBER EXCLUDED? � N/A N UB8D06048815 12/13/2015 12/13/2016
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ �,���,���
If yes, describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Job Reference: Professional Service Contract
CERTIFICATE HOLDER
City of Clearwater
Engineering, RFQ #34-15
P.O. Box 4748
Clearwater, FL 33758�748
CANCELLATION
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
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AO 1988-2014 ACORD CORPORATION. All rights reserved.
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